Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and care plans for two residents. One resident was observed lying in bed throughout multiple days, despite a care plan intervention requiring extensive assistance to get in and out of bed to a chair or wheelchair. Interviews with staff and the resident's representative revealed that the resident was only assisted out of bed when specifically requested by the representative, and there was no documentation or consistent practice to ensure the resident was mobilized as care planned. The Director of Nursing acknowledged that the resident should be up at least three days a week, but this was not documented or consistently implemented. Another resident with a history of Parkinson’s Disease, cerebral infarction, and range of motion impairment was not provided with a prescribed hand splint as ordered by the physician and outlined in the care plan and Kardex. Observations showed the resident’s contracted hand remained without a splint, and the resident reported that staff did not offer to put the splint on and that the splint was dirty and not cleaned by staff. Interviews with CNAs and an LPN revealed a lack of awareness regarding the need for the splint, and the DON was not aware that the splint was not being applied as ordered. Facility policies required that residents receive care to maintain or improve their ability to carry out activities of daily living, including mobility and the use of splints for contracture management. Despite these policies and specific care plan interventions, staff failed to consistently provide the required assistance and equipment, resulting in residents not receiving care as ordered and as per their preferences and goals.