Failure to Document and Administer Physician-Ordered Treatments and Delays in Specimen Collection
Penalty
Summary
Facility staff failed to maintain professional standards of care by not documenting wound care and treatments as directed by physicians for two residents. For one resident with mild cognitive impairment and at risk for pressure ulcers, staff did not document wound treatments on multiple occasions, including care for the tailbone, sacrum, heels, feet, and right great toe, as ordered by the physician. There was no documentation in the treatment administration records (TAR) or progress notes to indicate that treatments were provided, missed, or refused by the resident. Interviews with nursing staff confirmed that treatments were sometimes not completed due to resident refusal, absence for appointments, or disagreements between medical providers, but these reasons were not documented as required. Another resident, assessed as cognitively intact with diabetes, had physician orders for wound care to the right great toe. Staff failed to document the administration of wound treatments on several specified days, and there was no record in the TAR or progress notes explaining the missed treatments. Nursing staff acknowledged that documentation should be present if treatments were refused or not completed, but could not explain the lack of documentation. Additionally, staff failed to ensure timely collection and processing of a urine specimen for a resident with chronic kidney disease, peripheral vascular disease, diabetes, and other conditions. Although a physician ordered a urinalysis due to symptoms, the urine specimen was not collected until two days later and was not received by the lab until the following day. Furthermore, there was a delay in administering prescribed antibiotics for a diagnosed urinary tract infection, despite the medication being available in the facility's emergency kit. The DON confirmed that the expectation was for prompt collection of specimens and immediate initiation of treatment, but could not account for the delays.