Failure to Provide Timely Care and Notification for Change of Condition and Wound Management
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards and residents' preferences for two residents. One resident with a history of schizoaffective disorder, bipolar disorder, and Parkinson’s disease developed a facial laceration after surgery. Although the wound care nurse assessed the injury and was aware of the resident’s concern about potential scarring, no wound care orders were documented or implemented, and the resident was not informed of the care plan. The resident expressed a preference for ointment to prevent scarring, but her concerns were not addressed, and the physician was not properly notified until after surveyor intervention. Another resident with diagnoses including cardiomyopathy and type 2 diabetes with diabetic polyneuropathy reported episodes of numbness in her left arm and leg, as well as chest pain, to multiple nurses. Despite these symptoms representing a significant change in condition, the nursing staff did not document the events, notify the physician or responsible party, or complete a change of condition evaluation. Interviews revealed that the nurses believed the concerns had been addressed by other staff or by lab orders, but there was no communication or documentation to confirm this. The nurse practitioner stated she was not informed of the numbness or chest pain and would have taken further action if she had been notified. The facility’s policy requires prompt notification of the physician and responsible party in the event of significant changes in a resident’s condition, including life-threatening symptoms or clinical complications. In both cases, the required notifications, assessments, and documentation were not completed, resulting in a lack of appropriate care and communication regarding the residents’ conditions and preferences.