Failure to Notify Providers and Follow Diabetic and Wound Care Orders
Penalty
Summary
The facility failed to notify providers and family members of significant changes in residents' conditions and was unable to follow provider orders for diabetic care and wound management for multiple residents. For one resident with dementia and muscle weakness, staff identified a new skin wound but did not document a skin assessment or notify the provider or family until the wound was later found to be an unstageable sacral pressure injury. Documentation gaps were noted in weekly skin assessments, and there was no evidence of timely communication with the provider regarding the wound's development. Another resident with a stage 4 pressure ulcer did not receive prescribed wound care due to the facility running out of the required wound cleanser. The provider was not notified of the inability to complete the treatment as ordered, and the wound worsened significantly before the provider was made aware. Similar failures occurred in diabetic care, where residents with orders for frequent blood glucose monitoring and insulin administration missed scheduled checks and doses due to the facility running out of blood glucose monitoring strips. The provider was not notified of the missed checks or doses, and there was no documentation of attempts to obtain the necessary supplies through alternative means. For several residents with diabetes, blood glucose levels were not monitored as ordered, and insulin was administered without corresponding blood glucose readings. In some cases, residents received emergency glucagon injections for hypoglycemia without the provider being notified, and documentation of provider notification was missing. Interviews with staff and the DON confirmed these lapses in communication and documentation, as well as the lack of backup supplies and failure to notify providers when orders could not be followed.