Failure to Provide Necessary Services Upon Admission
Penalty
Summary
The facility failed to provide necessary services upon admission for a resident with multiple complex medical diagnoses, including diabetes, hypertension, chronic kidney disease, and obesity. Upon admission, there was no face sheet, initial admission assessment, or baseline care plan in the resident's medical record. Nursing staff documented that the resident was non-verbal, responsive only to painful stimuli, and on 7 liters of oxygen via trach collar. Although a head-to-toe assessment and vital signs were recorded, there was no documentation of height, weight, or blood sugar. The nurse who received the resident did not reconcile medications or obtain any orders, and the subsequent nurse did not administer any medications or initiate G-tube feeding, citing lack of information and inability to reach the physician for orders. Multiple staff interviews revealed that the feeding rate for the G-tube was not obtained from the hospital report, and the nurse did not connect the feeding or administer medications, waiting for a physician's response. The nurse did not seek assistance from the supervisor, and the supervisor was unaware that the resident had not received medications or feeding. The DON stated that urgent medications could be accessed from the facility's medication system and that the feeding rate was present in the admission papers. The nurse practitioner confirmed that alternative contacts and the dietician should have been involved if the physician was unavailable. The resident did not receive necessary medications or nutrition from admission until a code blue was called later that evening.