Failure to Provide Care in Accordance with Professional Standards
Penalty
Summary
The facility failed to ensure that three residents received care in accordance with professional standards of practice. For one resident with encephalopathy and Parkinson's Disease, a hand carrot orthotic was provided and in use without a physician's order, care plan entry, or therapy recommendation. The Director of Rehab admitted to providing the device without evaluation, and nursing staff were unaware of its use, indicating a lack of proper assessment and documentation. Another resident with dementia and skin impairment did not have a wound physician's recommendation for a bed cradle implemented, despite repeated recommendations documented in the medical record. Instead, staff used Prevalon boots as a substitute, although the wound physician clarified that these were not an appropriate replacement. The nurse practitioner declined the bed cradle recommendation without attempting its use or communicating this decision to the wound physician, and the care plan only referenced keeping pressure off the feet without specifying the bed cradle intervention. A third resident with diabetes and dysphagia did not consistently receive daily dressing changes to a left elbow wound as ordered by the physician. Observations showed a dressing dated two days prior, and documentation failed to confirm that the dressing was changed as required. The nurse responsible could not recall if the dressing was changed, and the weekly skin assessment did not mention the wound, indicating a failure to implement and document physician orders for wound care.