Failure to Provide Appropriate Treatment and Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for several residents, as evidenced by the observations and interviews conducted. Resident R16, who had a diabetic left plantar foot ulcer, did not have their wound dressing changed daily as ordered. The dressing was observed to be dated two days prior, and both the LPN and the Director of Nursing confirmed the failure to adhere to the physician's orders. Similarly, Resident R23, who had a vascular wound on the left shin, did not receive the required daily dressing changes. Despite the treatment administration record indicating compliance, the dressing was found to be unchanged for several days. The resident expressed that staff had been asked to change the dressing, but it was not done, a fact confirmed by the LPN and the Nursing Home Administrator. Resident R52 was administered Cefpodoxime without a physician's signature on the order, and during a change in condition, the facility failed to provide timely care. The resident experienced acute gastrointestinal pain and repeatedly called 911 for hospital transport. Despite the resident's deteriorating condition, there was no evidence of physician notification until the resident was eventually transferred to the hospital. Additionally, Resident R128 experienced a significant change in condition, including severe malnutrition and acute kidney injury, but the facility did not initiate necessary lab tests or identify hydration as a concern, leading to the resident's transfer to the hospital.
Plan Of Correction
1. The facility is unable to go back and make certain physician orders were followed and a resident received treatment and care in accordance with professional standards of practice. 2. DON completed a whole house wound investigation and found no other residents with dressings not changed per physician order and that the identified wounds with outdated dressings were not worsening. 3. DON/designee will complete a 30-day lookback of all current physician's orders to ensure they have been signed off. 4. DON/designee to educate licensed staff on following treatment orders/physicians orders including pharmacy ordering and first dose machine, readmission orders, notifying physicians timely with change in conditions. 5. DON to audit physician's orders including readmission orders and timely notification of change in conditions, and medication availability via pharmacy delivery or first dose system 5x/week for 2 weeks, then 3x/week for 2 weeks, and 1x/week for 2 weeks. 6. Results to be submitted to QAPI for review and approval.