Failure to Provide Necessary Care and Complete Required Assessments
Penalty
Summary
The facility failed to provide necessary care and services to several residents, as evidenced by incomplete treatments, lack of required assessments, and failure to follow physician orders. For one resident with multiple surgical wounds and complex medical needs, the facility did not complete a comprehensive admission assessment as required by policy, and wound care treatments were missed on specific dates. Additionally, blood glucose monitoring orders were not clarified or carried out, and the orders were not properly transcribed onto the Medication Administration Record, resulting in the monitoring not being performed. Another resident with dementia and psychiatric diagnoses was not accurately assessed for elopement risk. Despite multiple documented behaviors indicating confusion, exit-seeking, and attempts to leave the facility, the Elopement Risk Assessment was completed inaccurately, with key risk factors marked as absent. The Social Service Director responsible for the assessment did not review relevant nursing notes prior to completing the assessment, leading to an underestimation of the resident's elopement risk. For two additional residents with diabetes, insulin administration was not documented as given on several occasions, and corresponding blood glucose checks were also missing. The Medication Administration Records for these residents showed multiple instances where insulin doses were not signed out, and no explanation was provided by facility staff for these omissions. These failures affected residents with significant medical conditions, including diabetes, dementia, and other chronic illnesses, and were identified through record review, observation, and staff interviews.