Failure to Assess, Monitor, and Provide Timely Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. For one resident with chronic heart failure, sepsis, pressure ulcer, and Alzheimer's disease, there was a lack of assessment, monitoring, and action upon abnormal findings. The resident experienced a significant change in condition, including slurred speech, inability to assist with transfers, and coffee ground emesis, but there was no documentation of transfer to the hospital or death in the facility. Physician orders for vital sign monitoring were not followed, with vital signs often not recorded as ordered, and abnormal findings such as low blood pressure and low oxygen saturation were not addressed or communicated to the physician. Additionally, there was a delay in administering ordered IV antibiotics due to medication unavailability, and the physician was not notified of this delay. Skin assessments and care planning for pressure injuries were not completed timely or accurately, with missing documentation and delayed initiation of care plans and wound assessments. Another resident admitted with a history of lumbar spine fusion, UTI, and pelvic fracture did not receive antibiotics for a UTI in a timely manner, as the medication was not available upon admission and was started three days later. The care plan inaccurately reflected the presence of an indwelling catheter, which the resident did not have, and there was no documentation of orders to discontinue a catheter. Additionally, x-ray results ordered for this resident were not documented or followed up in the electronic medical record, and staff were unaware of the results until prompted. There was also a lack of communication and documentation regarding the resident's transfer needs and the use of appropriate transfer techniques. A third resident admitted with a surgical wound requiring a wound vac and a stage II pressure ulcer experienced delays in receiving the necessary wound vac supplies, resulting in alternative wound care and subsequent infection. Documentation of wound assessments was inconsistent, with discrepancies in wound measurements and lack of clear identification of wound sites. There was no evidence that the physician was notified of abnormal wound findings, such as foul odor and changes in wound condition, in a timely manner. Additionally, skin assessments were not completed as required, and documentation of dressing changes did not match observations, with dressings not in place as ordered. The facility lacked formal policies for admissions, transfers, discharges, and documentation of medical records, relying instead on standards of practice without clear protocols.