Failure to Provide Person-Centered Care and Timely Notification of Changes
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and residents' choices for two residents. One resident with a history of depression and recent surgery was admitted without a care plan containing resident-specific interventions for depression. This resident exhibited multiple depressive behaviors, including social isolation, refusals of care, and consistently low meal intake. Despite documentation of a significant 15.7% weight loss within 15 days of admission, the primary Nurse Practitioner was not notified, and no timely interventions were implemented. The dietician recommended a trial of Prostat for nutritional supplementation and a possible psychological evaluation, but no physician order was placed, and there was no evidence of interdisciplinary team consultation regarding the resident's nutrition. The resident continued to refuse meals and fluids, resulting in critically low fluid intake and minimal urine output over several days, yet neither the dietician nor the primary care provider was notified. When the resident's condition deteriorated, STAT labs were ordered but not processed as such, leading to delayed results. The resident was ultimately hospitalized with severe sepsis, C-diff infection, pulmonary embolism, and hypokalemia, and required intensive care. Upon return, the resident continued to have low intake and was readmitted to the hospital for dehydration and low potassium. Another resident experienced a fall from bed and was diagnosed with a closed head injury. Facility policy required neurological checks after a fall with head injury, but there was no evidence that these checks were completed. This failure to follow established protocols for post-fall assessment represents a deviation from professional standards of care. The facility's own policies outlined the need for person-centered behavioral health services, timely notification of changes in resident condition, and appropriate care planning and implementation. However, there were discrepancies among staff regarding responsibility for care plan development, and documentation showed a lack of communication and follow-through on critical changes in residents' conditions. The failures included not recognizing and addressing depressive symptoms, not responding to significant weight loss and poor intake, not notifying providers of critical changes, and not completing required post-fall assessments.