Failure to Provide Ordered Treatments, Skin Assessments, and PRN Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for three residents. One resident with hemiplegia was determined to require a custom Ankle Foot Orthosis (AFO) for stabilization and assistance with activities of daily living. Despite multiple clinical notes and evaluations indicating the need for a custom AFO, there was no evidence that the facility obtained the device. Staff interviews confirmed that no action had been taken to secure the orthosis, and the resident and family member both reported that the brace had not been received or used as ordered. Another resident was admitted with spastic hemiplegia and was found to have red blotches and bumps on both cheeks, which were present prior to admission and caused irritation. The facility's policy required identification, assessment, and documentation of skin impairments, as well as notification of the physician and obtaining treatment orders if needed. However, the skin condition was not assessed or documented by nursing staff, and no treatment was initiated. Staff interviews revealed that the skin issue was not reported or evaluated, and the required procedures for new skin impairments were not followed. A third resident with hypertension had a physician order for as-needed hydralazine to be administered for blood pressures greater than 160. Multiple blood pressure readings above this threshold were recorded, but there was no evidence in the medication administration record that the medication was given as ordered. Staff confirmed that the resident should have received the medication when indicated, but this did not occur.