Failure to Complete Required Assessments and Care Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents’ care plans in several areas. For two residents, staff did not complete weekly skin assessments as required. One resident with malnutrition and cancer had a care plan intervention for weekly skin checks, but there were gaps of up to three weeks between documented assessments, and some skin checks were recorded on the treatment administration record without corresponding assessment forms. Another resident, at risk for pressure ulcers following major surgery, also did not receive weekly skin checks as ordered, with a gap of nearly five weeks between documented assessments. In another instance, staff did not complete a post-fall assessment for a resident who experienced a fall in the bathroom while being assisted by staff. The resident was at moderate risk for falls, and facility policy required a fall assessment after each incident, but no updated assessment was found in the records following the event. Additionally, a resident discharged from therapy services did not receive a referral to a restorative nursing program to maintain range of motion, despite the therapy department’s usual practice and the resident’s ongoing need for assistance with daily activities. The therapy discharge summary lacked documentation of a referral, and both the restorative coordinator and rehab director confirmed the omission. The facility also failed to monitor a resident’s weight according to physician orders. One resident receiving tube feeding had a physician order for monthly weight monitoring, but records showed missing weights for several months. The care plan included an intervention to monitor weight per order, but this was not consistently implemented. These failures were confirmed by staff interviews and record reviews.