Failure to Follow Physician Orders for Skin Assessments and Timely Swallow Study
Penalty
Summary
The facility failed to provide quality care that meets professional standards for a resident with multiple diagnoses, including metabolic encephalopathy, dysphagia, moderate malnutrition, weakness, and dementia. Staff did not follow physician orders for weekly skin assessments, as evidenced by gaps in documentation and missed assessments over several weeks. The resident developed a stage 2 pressure ulcer and had ongoing skin issues, but weekly assessments were not consistently completed as ordered. Both a registered nurse and the interim director of nursing confirmed that the weekly skin assessments were not performed as required by the physician's orders. Additionally, the facility did not obtain a physician's order and complete a swallow study in a timely manner after it was recommended by the speech language pathologist (SLP). The SLP documented several recommendations for a swallow study over multiple weeks before an order was finally placed and the study was completed. Interviews with the SLP and the interim director of nursing confirmed that the delay was due to a lack of timely communication and follow-through between nursing staff and therapy, resulting in a significant delay in addressing the resident's swallowing difficulties.