Failure to Provide Care and Treatment According to Orders and Standards
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for three residents. For one resident with legal blindness and diagnoses of glaucoma, entropion, and dry eye, the eye doctor ordered specific eye ointment and drops to be administered regularly. However, a review of the medication administration records over several months showed that these medications were neither ordered nor administered as prescribed. Another resident with a history of falls experienced unwitnessed falls on two occasions. Post-fall neurological assessments were incomplete, with missing documentation of the COMA scale, vital signs, and hand grip assessments at various required intervals. Additionally, some scheduled neuro checks were not documented at all, as confirmed by facility leadership. A third resident, who had a nephrostomy tube placed following hospitalization for septic shock and pyelonephritis, requested tube flushes upon return to the facility. There was no documentation that this request was communicated to a physician in a timely manner, resulting in a delay before an order was obtained. Furthermore, the nephrostomy tube was flushed by nursing staff prior to obtaining a physician's order, contrary to facility policy requiring such an order for nephrostomy care.