Failure to Provide Timely Wound, Blood Sugar, Weight, Blood Pressure, and Oral Care
Penalty
Summary
A resident with multiple complex medical conditions, including encephalopathy, sepsis, diabetes mellitus II, muscle wasting, and hypertension, was admitted to the facility. The facility failed to provide necessary care and treatment in several areas. The resident's left forehead laceration, which had six sutures, was not evaluated or referred to a physician for suture removal during the fourth week of stay. Documentation and interviews confirmed that no wound or suture evaluation was conducted, and the healing surgical wound with sutures was not reported to a physician as required by facility policy. Additionally, after the discontinuation of insulin medication, the resident's blood sugar levels were not monitored, despite a diagnosis of diabetes and care plan instructions to check blood glucose. The last documented blood sugar level was recorded on the day insulin was discontinued, with no further monitoring or clarification from nursing staff to the physician regarding ongoing blood sugar checks. This lapse was acknowledged by both nursing staff and the DON, who confirmed that blood sugar monitoring should have continued per facility protocol. The facility also failed to obtain the resident's baseline weight in a timely manner after admission, with a two-day delay in obtaining the initial weight. This delay was recognized by both the restorative nursing assistant and the RN, who stated that timely weight measurement is necessary for appropriate nutritional management. Furthermore, the resident experienced a change in condition with low blood pressure readings, but this was not reported to a physician as required by policy. Lastly, oral care was not provided after a meal, despite the resident's severe cognitive impairment and dependence on staff for oral hygiene, resulting in food residue being found in the resident's mouth during a subsequent physician appointment.