Failure to Initiate Admission Assessments and Physician Orders; Incomplete Wound Care Documentation
Penalty
Summary
The facility failed to ensure that a newly admitted resident's immediate care and service needs were assessed and that physician orders were initiated at the time of admission. The resident, who had multiple complex diagnoses including local skin infection, non-pressure ulcers on both lower legs, peripheral vascular disease, diabetes, hypertension, COPD, and major depressive disorder, was admitted without an admission note, physician notification, or verification of admission orders. Medication reconciliation and initiation of critical treatments, including antibiotics, pain management, insulin, and wound care, were delayed until one to two days after admission. Required assessments such as vital signs, height, and weight were also not completed upon admission. The report further details that the admitting nurse did not complete any of the required admission assessments or initiate any of the admitting physician orders from the hospital. This resulted in missed medications, treatments, and assessments for the resident during the initial period of their stay. The facility's policy required a systematic evaluation and prioritization of resident needs upon admission, including medication reconciliation and implementation of all hospital orders, which was not followed in this case. Additionally, the facility failed to provide wound care treatments according to physician orders for another resident. The resident had an order for daily wound care to the right lower leg, but the treatment was not performed as ordered on one occasion. Furthermore, a dressing was applied to the left lower leg without a physician's order or documentation, and the physician was not notified of the new open area. Facility policy required appropriate treatment selection, obtaining a physician's order, and documentation in the treatment administration record, which was not adhered to in this instance.