Failure to Provide Care and Timely Response After Falls and Medical Events
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for multiple residents. In one instance, a resident with chronic congestive heart failure, seizures, diabetes, and anxiety was ordered by a physician to be sent to the emergency room for fluid overload and seizure activity. The resident was transported via non-emergency taxi without an escort, resulting in the resident waiting 20 minutes outside the emergency room before being assisted inside. Staff interviews revealed inconsistent practices regarding escorts for non-emergency transports, and the physician was not aware that the resident was unescorted. In another case, a resident who fell off the bed did not have the incident documented in the medical record on the day of the fall, and there were no follow-up assessments or timely physician notification. The first documentation occurred at least 12 hours after the fall, and vital signs recorded did not correspond to the time of the incident. The facility's policy required immediate notification and monitoring after a fall, which was not followed. The LPN involved admitted to forgetting to document the incident and not being familiar with the process at the time. Additional deficiencies included failure to conduct and document neurological checks after unwitnessed falls for two residents, despite facility policy requiring specific intervals for such assessments. In one case, neuro checks were not performed at all after four unwitnessed falls, and in another, the checks were completed at incorrect intervals and with inaccurate data. Furthermore, a resident with a history of intracerebral hemorrhage and recent skull surgery was not sent to the emergency room in a timely manner after a fall, despite an order for immediate transfer for imaging. These findings were confirmed through medical record reviews and staff interviews.