Failure to Provide and Document Appropriate Care and Services
Penalty
Summary
The facility failed to provide necessary care and services to three residents, resulting in deficiencies related to assessment, documentation, and communication of care needs. For one resident, a black scab under the second right toenail and dryness on both feet were observed, but these conditions were not addressed in the comprehensive skin assessment. Although a podiatry visit had recommended applying lotion to restore moisture, the wound care nurse was unaware of these additional foot conditions, and there was no documentation that the recommendations were followed. Another resident experienced a fall, and the facility did not complete or accurately document the required post-fall neurological assessments and monitoring. Several neurological assessment components, such as pupil response, extremity motor function, and pain response, were missing or not completed at multiple required intervals. Additionally, progress notes did not reflect post-fall monitoring during several shifts, contrary to facility policy that mandates such monitoring every shift for 72 hours post-fall. A third resident, who had specific swallowing and diet recommendations from an acute care hospital, was observed being assisted with thickened liquids using a straw, despite discharge instructions specifying that liquids should be given by spoon only. There was no evidence that these recommendations were communicated to the attending physician or incorporated into the resident's care plan. Staff interviews confirmed the lack of documentation and awareness regarding the required feeding method.