Failure to Perform Timely Post-Fall Assessments and Adhere to Physician Orders for Diabetic Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for multiple residents. For one resident with encephalopathy and heart failure, there were two documented falls within a short period. Despite policy requiring a post-fall assessment and investigation within 24 hours, the clinical record did not contain evidence of such assessments after either fall. The Director of Nursing confirmed that the required fall risk evaluations were not completed, and there was a lack of documentation in the medical record regarding the falls and subsequent assessments. Another resident with diabetes, a foot ulcer, repeated falls, and dementia did not have updated or consistent physician orders for wound care, despite podiatry notes indicating changes in wound treatment. The Medication Administration Record (MAR) showed that wound care was provided inconsistently with the orders, and there was no documentation of a physician's order for weekly dressing changes at podiatry visits. Additionally, this resident did not receive insulin on several occasions due to blood sugar readings, but there was no documentation that the physician was notified as required. Blood sugar checks were also incompletely documented, with only one daily reading recorded despite orders for checks before meals and at bedtime. A third resident with diabetes had physician orders for blood sugar checks and insulin administration every six hours. However, the MAR lacked documentation of blood sugar readings and insulin administration on multiple occasions. The facility's policy required that vital signs and test results be recorded prior to medication administration and that any held medications be documented with reasons. The Director of Nursing confirmed that the required documentation was missing for these instances.