Failure to Provide Care per Physician Orders and Timely Address Change in Condition
Penalty
Summary
The facility failed to provide care in accordance with physician orders and did not timely identify or address a significant change in condition for a resident with Alzheimer's disease, COPD, and hypertension. The resident had care plans in place for nutritional monitoring and incontinence, as well as physician orders for weekly weights and daily wound care. However, documentation revealed that wound care was not provided on multiple ordered dates, and weekly weights were missed, including during a period of significant weight loss. The resident experienced a 7.5% weight loss in less than 30 days, but there was no evidence that the physician was notified of this severe decline, nor were further weights documented after the initial identification of weight loss. From 03/16/25 to 03/22/25, there was no documentation or physician notification regarding changes in the resident's baseline mentation, eating patterns, or activity level, despite the resident exhibiting a decline in these areas. Nursing notes only documented the resident's condition after family members expressed concern and insisted on hospital transfer. The facility's own policy required staff to document and notify the physician and family of significant changes in condition, but this was not followed. Upon transfer to the hospital, the resident was diagnosed with sepsis related to aspiration pneumonia, fecal impaction, acute metabolic encephalopathy, and urinary tract infection. Hospital records indicated the presence of a fecal impaction, a severe urinary tract infection, and aspiration pneumonia, all of which were not addressed or communicated by facility staff prior to transfer. Interviews with facility leadership confirmed the missed wound care, lack of documentation, and failure to notify the physician or family of the resident's decline.