Failure to Provide Necessary Care, Timely Provider Notification, and Pain Management
Penalty
Summary
The facility failed to provide necessary care and services as ordered and according to residents' preferences and goals, resulting in multiple deficiencies. For one resident with a history of neurogenic bladder and recurrent UTIs, the facility did not follow physician orders for a silver-coated Foley catheter, failed to change the catheter as scheduled, and did not order or document required laboratory tests to monitor for infection. The resident experienced escalating pain, which was documented but not adequately addressed, and there was a lack of timely provider notification regarding abnormal findings. Ultimately, the resident developed a severe UTI that progressed to Fournier's gangrene and sepsis, with hospital records indicating the resident had been requesting to go to the emergency room for weeks due to feeling unwell and experiencing foul-smelling drainage. Another resident with a UTI did not receive the full course of prescribed antibiotics, with only three out of five doses administered. There was no documentation explaining the missed doses or indicating that the provider was notified of the incomplete antibiotic therapy. This lapse in care placed the resident at risk for worsening infection or delayed recovery. Additionally, the facility failed to ensure that providers were notified of abnormal laboratory results for two other residents. In both cases, there was no documentation that the physician was informed of critical lab values, despite facility policy requiring prompt notification and documentation of such events. The facility also failed to manage pain appropriately for another resident who reported significant pain upon admission. Despite documented pain levels of 6 out of 10 and orders for pain medication, the resident did not receive any pain medication for two days, and there was no documentation of provider notification or explanation for the delay. Interviews with staff confirmed that pain of this severity should have prompted provider contact and administration of ordered medications. Facility policies reviewed emphasized the importance of timely pain management, provider notification, and documentation, all of which were not followed in these cases.