Failure to Provide Timely Wound Care and Interventions for Pain and Confusion
Penalty
Summary
The facility failed to provide necessary care and treatment for two residents by not reevaluating and treating wounds and not implementing interventions after reports of pain and confusion. For one resident with severe cognitive impairment and multiple mental health diagnoses, the care plan indicated that skin tears should be treated per protocol and the physician notified. Despite ongoing observations of the resident scratching herself, resulting in bleeding wounds on her arms and legs, there was no evidence of reevaluation or notification to the physician when treatments proved ineffective. The resident's care plan also lacked documentation for a prescribed ointment, and both the registered nurse and the director of nursing acknowledged that a care plan should have been in place to ensure continuity of care. For another resident with severe cognitive impairment and multiple medical conditions, including a history of shoulder dislocation and chronic respiratory issues, the facility did not provide appropriate interventions after the resident and family reported pain and episodes of confusion. Nursing notes indicated that the family expressed concerns about a possible fall and ongoing pain, but there was no documentation of a change of condition assessment, physician notification, or implementation of monitoring protocols such as neuro checks or 72-hour monitoring. Staff interviews confirmed that these steps were not taken, and the care plan was not updated to reflect the resident's current status. Facility policies required notification of the physician and the interdisciplinary team, assessment and documentation of changes in condition, and updates to care plans when there is a significant change in a resident's status. In both cases, these procedures were not followed, resulting in a lack of timely and appropriate care for the residents involved.