Failure to Provide Care and Treatment According to Professional Standards
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards for multiple residents, as evidenced by direct observations, record reviews, and staff interviews. For one resident with a right-hand contracture, the care plan did not address the contracture, and there was no documentation of ongoing assessment, monitoring, or specific nursing interventions for the contracture. Staff were unaware of any specific orders for the care of the contracture, and there was evidence of pain and skin issues, such as yellow crust between the contracted fingers, that were not reported or managed according to policy. The interdisciplinary approach required by facility policy was not implemented, and the contracture was not accurately reflected in the Minimum Data Set (MDS) assessments. Another resident with venous ulcers and lymphedema did not receive ace wraps to the lower extremities as ordered by the physician. Instead, the resident was observed multiple times with kerlix wraps and without the prescribed ace wraps, and the treatments were not completed before the resident was out of bed, as required. Additionally, weekly skin checks ordered by the physician were not consistently performed or documented, with only 3 out of 13 checks completed over a three-month period. Staff interviews confirmed that treatments and assessments were missed due to workload and lack of communication, and the facility's policies for implementing physician orders and documenting skin checks were not followed. A resident prescribed a Budesonide-Formoterol inhaler was found to have the inhaler at the bedside for self-administration without a completed self-administration assessment or a physician order permitting self-administration. The resident reported using the inhaler as needed without knowledge of the correct dosage or schedule, and the medication was not stored securely as required by policy. In another case, a resident with diabetes and a history of blood sugar fluctuations had an elevated blood sugar reading that was not followed by an RN assessment or proper documentation. The LPN involved could not recall if the appropriate notifications were made, and there was no evidence in the clinical record of follow-up or interventions as required by the facility's hyperglycemia management policy.