Failure to Provide Care Consistent with Standards of Practice Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for three residents, resulting in significant adverse outcomes. In one case, a resident with a history of dysphagia, respiratory failure, and psychological disorder reported swallowing a stress ball. Staff did not contact poison control to determine the toxicity of the ball's contents, did not complete a Registered Nurse (RN) assessment including respiratory, abdominal, or pain assessments, and inaccurately reported to the Nurse Practitioner (NP) that the ball was retrieved without having it in possession. The resident requested to go to the hospital but was not sent until the following day, despite expressing distress and pain. Orders from the NP for close monitoring were not followed, and the resident's care plan was not updated to prevent recurrence. The resident ultimately developed a high-grade small bowel obstruction requiring surgical intervention and a six-day hospitalization. Another resident with diabetes and a history of serious ankle fracture developed cellulitis in the right third toe, which progressed to gangrene and possible osteomyelitis. The facility did not initiate the prescribed antibiotic in a timely manner, failed to monitor, assess, or document the wound, and did not complete or document required diabetic foot checks. Wound care orders from podiatry were not carried out, and the wound was not measured or assessed as required. The resident's care plan was not updated to reflect the infection, wound, or subsequent amputation of all five toes on the right foot. A third resident developed a vascular ulcer on the right leg. Staff failed to transcribe wound and antibiotic orders to the Treatment Administration Record (TAR), resulting in missed treatments and a four-day delay in antibiotic administration. Weekly wound assessments and measurements were not completed, and a person-centered care plan for the vascular ulcer was not developed. The ulcer deteriorated and became infected, leading to hospitalization for cellulitis and intravenous antibiotics. Across these cases, the facility did not complete RN assessments with changes in condition, did not follow provider orders, and failed to document and implement required care and monitoring, resulting in immediate jeopardy.