Multiple Failures in Resident Care, Assessment, and Implementation of Physician Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident preferences in several instances. One resident with quadriplegia and a history of neurogenic bowel was not comprehensively assessed or provided with a bowel management program that met her expressed needs. Despite clear documentation of her prior successful use of digital stimulation for bowel movements and multiple provider orders supporting this intervention, staff repeatedly told her it was against facility policy and did not implement the ordered regimen. The care plan and medical record lacked any rationale for denying digital stimulation, and staff were unaware of the actual facility policy, which did not prohibit the procedure. As a result, the resident experienced ongoing constipation and frustration, with minimal recorded bowel movements over an extended period and no effective interventions provided despite available PRN medications and standing orders. Another deficiency involved the failure to act upon a physician order for a diabetic monitoring device. A resident with diabetes had an order for a FreeStyle Libre device to reduce the need for frequent finger sticks. The device was not provided or applied in a timely manner, and documentation showed it was marked as "not available" without evidence of follow-up or action to obtain it. Staff interviews revealed a lack of awareness and communication regarding the order, and the device was only pursued after surveyor inquiry, resulting in unnecessary distress for the resident due to continued finger sticks. Additional deficiencies included the failure to assess and treat a new skin condition for a resident, as weekly skin checks and documentation were not completed as required, and staff were unaware of the resident's needs for facial skin care. Another resident's request for a diet modification was not timely referred for evaluation, as staff did not communicate the request to the appropriate clinical team, resulting in a delay in addressing the resident's dietary preferences. The facility also failed to ensure that medical devices for edema management were consistently applied according to orders, with staff demonstrating a lack of knowledge about the correct procedure and documentation not matching observed care. Lastly, a resident's hearing concerns were not recognized or comprehensively assessed, leading to a delay in identifying and treating cerumen impaction.