Failure to Provide Care and Documentation per Orders and Standards
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and professional standards for multiple residents. For one resident with a history of epilepsy, gastrostomy, and dysphagia, the facility did not complete or document an RN assessment after the dislodgement of a feeding tube, nor did they notify the provider on the day of the incident. There was also a lack of documentation regarding the resident’s removal or self-discontinuation of the G-tube, and weights were not consistently obtained or recorded as ordered by the physician. The clinical record showed significant gaps in weight monitoring, and weights provided by therapy staff were not entered into the resident’s clinical record. Interviews confirmed that staff did not document or communicate key events, and the facility’s own policies on weight monitoring and documentation were not followed. Another resident with congestive heart failure and severe protein calorie malnutrition had a physician’s order for daily weights, which were not consistently obtained or documented on numerous days over several months. When the resident refused weights, there was no documentation of education, re-approach, or notification to the physician or APRN, despite repeated refusals. The care plan did not address refusals of care, and interviews with staff and leadership confirmed that documentation and follow-up were inconsistent or absent. The facility’s policies and guidelines for inotrope therapy, which emphasize the importance of daily weights, were not adhered to in this case. A third resident, with chronic kidney disease and a history of returning from leave of absence or dialysis smelling of marijuana, did not receive care in accordance with professional standards. There was no documentation of assessments upon return, notification to the physician or dialysis center, or education provided to the resident regarding the impact of drug use. The facility also failed to maintain required documentation such as a smoking agreement or smoking assessment, and did not document room searches or the retrieval of smoking materials. Interviews revealed that staff were aware of the issue but did not consistently document or communicate it, and the facility’s smoking policy requirements were not met.