Failure to Prevent Neglect in ADL Assistance, Medication Administration, and Timely UTI Treatment
Penalty
Summary
The facility failed to protect residents from neglect by not providing necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress for several residents. One resident with significant mobility impairments and at risk for pressure ulcers did not receive timely assistance with activities of daily living (ADLs), including bathing, oral care, and toileting. Documentation and interviews revealed that this resident went without a shower for over a month and had to wait extended periods for perineal care after incontinence episodes, primarily due to insufficient staffing and the need for two staff members to safely transfer the resident using a ceiling lift. The lack of timely and consistent ADL care led to the resident feeling uncomfortable, down, and emotionally distressed. Two other residents did not receive their prescribed medications as ordered. One resident with chronic kidney disease and diabetes missed multiple doses of sodium bicarbonate because the medication was not available in the medication cart, as confirmed by both the resident and medication administration records. Another resident with epilepsy missed several doses of Celotin, an anti-seizure medication, due to repeated unavailability from the pharmacy. This resident and their power of attorney expressed concern about the missed doses, and documentation showed that alternative medications were sometimes used, but not always, and that communication and documentation regarding the missed doses were inconsistent. A fourth resident experienced a significant delay in receiving appropriate and timely treatment for symptoms of a urinary tract infection (UTI). Despite repeated requests and multiple orders for urine analysis (UA), several samples were either not sent to the lab, lost, or contaminated, resulting in a delay of over a month before antibiotics were started. The resident continued to experience pain and discomfort during this period, and there was no evidence that a provider assessed the resident for UTI symptoms after abnormal UA results were received. Facility policies and job descriptions reviewed indicated that the care provided did not meet the required standards for timely and adequate care, medication administration, and follow-up on resident symptoms.