Failure to Provide Care According to Professional Standards and Resident Needs
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for two residents. One resident with rheumatoid arthritis, spinal stenosis, and a history of falls was dependent on staff for all activities of daily living and had moderate cognitive impairment. Occupational therapy had recommended and trained staff to apply custom-made hand splints daily to maintain and improve hand range of motion. Despite these recommendations and documented progress during therapy, there was no documentation in the care plan, Kardex, or physician orders for the continued use of hand splints after discharge from therapy. Multiple observations confirmed the resident was not wearing splints, and interviews with staff revealed a lack of awareness and follow-through regarding the splint orders. The resident experienced a loss of range of motion, regressing to their initial condition upon admission, which was attributed to the lack of splint use and a breakdown in communication between therapy, nursing, and care planning staff. Another resident, recently readmitted with chronic kidney disease and a nephrostomy tube, did not have any orders or documentation for nephrostomy tube care or flushing upon admission. The treatment administration record showed no evidence of nephrostomy care, and observations revealed the tube was not properly dressed or secured. The resident was later found on the floor with a dislodged nephrostomy tube and was transferred to the hospital. Interviews with staff and the medical director confirmed that there should have been orders for dressing changes and tube flushing, and that the admitting nurse should have clarified care requirements with the provider. The facility was unable to provide documentation that nephrostomy care was included in the care plan or treatment record during the initial admission. Facility policies required that assistive devices and equipment recommendations be documented in the care plan and that nephrostomy tube care be based on physician orders, with staff responsible for monitoring and reporting issues. In both cases, the lack of proper documentation, communication, and follow-through led to residents not receiving care as recommended by professional standards and as required by facility policy.