Failure to Provide Timely Treatment, Assessment, and Medication Administration
Penalty
Summary
The facility failed to provide necessary treatment and services for multiple residents as evidenced by several deficiencies. One resident with severe cognitive impairment and a recent pacemaker surgery had a dressing that was not fully adhering to the skin, with the incision sometimes visible. The resident was instructed to keep the dressing on until a follow-up appointment, which was delayed because the Medical Records Coordinator was unable to reach the physician's office for two weeks and did not escalate the issue to other staff. The Director of Nursing was unaware of the delay in scheduling the required post-operative appointment. Another resident with moderate cognitive impairment, Parkinson's Disease, and peripheral vascular disease exhibited visible swelling in the legs and feet during multiple observations and was not wearing the prescribed compression sleeves. The resident's record showed a lack of regular assessment of edema, despite physician orders and care plan interventions to monitor and report increased swelling. Additionally, a third resident with diabetes and an amputation had scheduled insulin doses held without physician orders or documented parameters, contrary to the care plan that required medications to be given as ordered. These findings were confirmed through record review and staff interviews.