Failure to Provide Timely Care, Medication, and Monitoring per Physician Orders
Penalty
Summary
The facility failed to provide timely and appropriate treatment and care according to physician orders and residents' needs in several instances. For one resident, laboratory work was not obtained in a timely manner, with significant delays between the ordering and collection of blood and stool tests. Documentation was lacking regarding when orders were received, when labs were obtained, and when results were communicated to the provider. The DON confirmed that staff did not document refusals, collection, or notification of lab results as required by facility policy. In multiple cases, residents did not receive prescribed medications due to unavailability, and there was no evidence that the facility took appropriate steps to address the situation. One resident missed seven days of an anticoagulant medication, while another missed several days of blood pressure medication, aspirin, and electrolyte replacement. The facility did not document efforts to determine the cause of the unavailability, did not notify the physician, and did not monitor the residents for adverse effects during the period the medications were not administered. The DON confirmed these lapses and the absence of required documentation and follow-up. Additional deficiencies included failure to monitor and document a resident's fluid restriction, with intake exceeding the prescribed limit on multiple occasions and no evidence of physician notification or documentation of the reason for the restriction. Another resident did not receive prescribed eye drops or compression garments as ordered, with delays in obtaining the necessary supplies and lack of timely physician notification. Furthermore, a resident with a pressure injury did not have weekly wound assessments or documentation as required by facility policy. These failures were confirmed through interviews and record reviews.