Failure to Perform Ordered Weights and Obtain Wound Care Orders
Penalty
Summary
The facility failed to provide care and services that meet professional standards of quality by not performing resident weights as ordered and not obtaining physician orders for wound care. Specifically, three residents with significant weight loss or at risk for weight changes were not weighed weekly as required by facility policy and as recommended by the registered dietician. For example, one resident experienced a 5% weight loss over 30 days and was not weighed weekly after this was identified, another resident was not weighed weekly as indicated in their care plan, and a third resident with significant weight loss also missed weekly weights despite dietician recommendations. These lapses were confirmed by the Director of Nursing (DON) during interviews, who acknowledged that the required weekly weights were not performed. Additionally, the facility failed to input physician orders for wound care for a resident with active wounds. Observation revealed bandages on both forearms of the resident, but there were no active treatment orders for these wounds in the medical record. The treatment nurse and DON both confirmed that physician orders should have been in place for all active wounds, but were not obtained for this resident.