Failure to Provide Timely and Appropriate Care and Documentation for Multiple Residents
Penalty
Summary
Resident #72, who had mild cognitive impairment and a foot infection, was ordered to receive daily wound care with betadine to the right foot, with the dressing to be changed during the evening shift and as needed for soiling or dislodgement. The care plan was revised to accommodate the family's request for evening treatments. However, after a morning shower, the resident was left without a dressing, and staff failed to notice or address the missing dressing or the condition of the foot, which was observed to be necrotic and emitting a strong odor. The responsible RN was unaware of the dressing's status and had not performed the dressing change, despite clear evidence that it was needed after the shower. Resident #69, who had a terminal diagnosis and was receiving hospice services, did not have a current physician order for hospice services in the medical record, despite a hospice consult being requested and the resident being admitted to hospice. The Assistant Director of Nursing confirmed the absence of the required order during a review of the record. Resident #25 experienced a delay in treatment for a urinary tract infection (UTI) after a urinalysis and culture indicated the need for antibiotics. Although the lab results were faxed to the physician, there was no follow-up call, and antibiotic treatment was not initiated until four days later. Additionally, Resident #38, who was at high risk for skin tears and had physician orders for geri sleeves to be applied to both arms and legs every shift, was observed without the required sleeves. Staff were unaware of the full extent of the order, and there was a lack of communication and documentation regarding the resident's refusal or acceptance of the sleeves.