Failure to Follow Physician Orders and Provide Comprehensive Resident-Centered Care
Penalty
Summary
The facility failed to provide comprehensive, resident-centered care as evidenced by multiple deficiencies in following physician orders, documenting care, and notifying providers of significant changes in residents' conditions. For several residents, there were repeated lapses in the administration and documentation of prescribed treatments, such as wound care and nutritional supplements. For example, one resident with multiple comorbidities including diabetes and skin breakdown did not consistently receive ordered wound treatments or nutritional supplements, and there was no documentation of provider notification when these treatments were missed. Additionally, this resident received insulin outside of the prescribed sliding scale without appropriate physician orders or notification when blood glucose levels exceeded the threshold requiring provider contact. Other residents experienced similar failures in care. One resident with a history of stroke and impaired mobility had orders for weekly skin checks, but there were multiple periods where no documentation of these assessments was found. Another resident, at risk for pressure ulcers and with significant medical complexity, also did not have weekly skin checks documented as ordered. In the case of a resident with congestive heart failure, there was a significant, rapid weight gain over several days, but the physician was not notified in a timely manner as required by facility protocol and physician orders. Staff interviews confirmed a lack of awareness of the resident's diagnoses and a failure to conduct thorough record reviews, contributing to the missed notifications. Additionally, a resident on anticoagulant therapy did not have weekly skin assessments completed for an extended period, and significant bruising was observed but not documented or monitored as required by the care plan. This resident also experienced interruptions in receiving a prescribed protein supplement due to supply issues, with no evidence that the provider was notified or alternative options were considered. These deficiencies were confirmed through record reviews, staff interviews, and direct observations, affecting multiple residents and demonstrating a pattern of non-compliance with physician orders and care protocols.