Failure to Provide Care and Treatment According to Physician Orders and Facility Policy
Penalty
Summary
Multiple residents did not receive care and treatment in accordance with physician orders, care plans, and facility policies. Several residents with physician orders for compression stockings were repeatedly observed not wearing them, despite documentation in their care plans and treatment administration records indicating they should be applied daily. There was no documentation in the medical records to explain the absence of the stockings, and staff confirmed that the expectation was for the stockings to be applied or refusals to be documented. Residents themselves confirmed that staff had not been applying the stockings as ordered. One resident with a vascular/venous stasis ulcer did not receive a prescribed treatment on a specific date, and there was a delay in providing an ordered air mattress. The resident reported having to request the air mattress multiple times and experienced discomfort due to the delay. Documentation confirmed the air mattress was not provided until several days after the physician order, and the wound treatment was not completed as scheduled, with staff citing workload as a reason for the missed care. Another resident experienced an unwitnessed fall, and the facility failed to complete and document neurological checks as required by facility policy for unwitnessed falls. The fall packet and checklist were incomplete, and staff interviews confirmed that neuro checks should have been performed and documented but were not. The DON and other staff acknowledged the lack of documentation and completion of required post-fall assessments.