Failure to Accommodate Resident Needs and Preferences Upon Admission
Penalty
Summary
The facility failed to ensure reasonable accommodation of resident needs and preferences upon admission for two residents. One resident, admitted with multiple fractures and severe pain, did not receive prescribed pain medication for approximately seven hours after arrival, despite orders for oxycodone and documented severe pain. The resident was also left without necessary mobility devices, such as a walker or wheelchair, and was unable to transfer out of bed or access the commode due to the lack of equipment. Staff informed the resident and family that therapy assessments and equipment provision would not occur until the next day, resulting in the resident remaining bedbound and experiencing significant discomfort. The resident and family reported that staff were unprepared to assist with mobility and pain management, and that communication regarding medication availability was lacking. Another resident, admitted with a new colostomy and chronic pain, experienced delays in care and assistance. The resident was found lying in urine with the call light on and waited an hour for help on the first night. On another occasion, the resident waited two hours for assistance with a colostomy bag change, leading a family member to perform the task themselves. When a nurse eventually arrived, she was unfamiliar with how to change the colostomy bag, indicating a lack of staff preparedness and training for the resident's needs. Interviews with staff revealed that therapy assessments and equipment provision were often delayed on weekends, and that nursing staff were hesitant to provide mobility devices without therapy input. Staff also indicated that pain medication could be accessed from the emergency kit, but this was not done promptly for the resident in pain. The facility's processes and communication breakdowns resulted in residents not receiving timely pain management, mobility support, or personal care upon admission.