Failure to Provide Resident-Centered Care and Timely Physician Notification for Insulin and Wound Care
Penalty
Summary
The facility failed to identify and provide needed care and services that were resident-centered and in accordance with the resident's preferences, goals for care, and professional standards of practice for one resident. Upon admission, the resident, who had a history of insulin-dependent diabetes mellitus and a diabetic ulcer, informed staff that her insulin had been discontinued in error at the hospital and requested that the provider be contacted to clarify and reinstate her insulin orders. Despite repeated requests from the resident over several days, the nursing staff did not contact the provider for clarification or obtain new orders for insulin or wound care. The resident continued to self-administer her own insulin using a personal insulin pen, without an assessment for self-administration, and without facility orders or documentation for this medication. Additionally, the resident had a diabetic ulcer on her toe that was covered with a dressing upon admission. She requested wound care and dressing changes, but was told there were no orders for wound care. Although the dressing was changed by nurses on two occasions, the resident was unsure of the treatment used, and there was no documentation of wound care orders or treatments until several days after admission. The RN Treatment Nurse did not assess the wound until several days after admission, at which point a new wound care order was obtained from the Nurse Practitioner. Documentation revealed that the facility's policy required immediate implementation of resident-specific interventions and prompt notification of the physician when an open area was identified, which was not followed in this case. Interviews with facility staff, including the DON and RN Treatment Nurse, confirmed that the resident's requests for insulin and wound care were not addressed in a timely manner, and that appropriate notifications to providers were not made. The DON acknowledged that the resident had the right to necessary treatments and medications, and that the facility failed to obtain orders for both wound care and insulin, resulting in a lack of appropriate treatment and care according to the resident's needs and preferences.