Failure to Provide Timely Pain Management, Nutrition, and Injury Assessment
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the comprehensive care plan, and resident choices for two residents. One resident, who had recently undergone digestive system surgery and had multiple complex diagnoses including sepsis, diabetes, and ulcerative colitis, was not provided with post-surgical pain medication for more than 48 hours after admission. Additionally, this resident did not receive enteral feeding or hydration for over 19 hours after admission, despite orders for continuous tube feeding and water flushes. The resident also did not receive appropriate colostomy/ileostomy care, resulting in fecal leakage and skin breakdown, and was ultimately transferred to an acute care hospital with a rash around the stoma. Documentation was lacking regarding the administration of pain medication and enteral feeding, and there was no evidence of timely reconciliation or implementation of physician orders. Another resident was not provided with proper care and assessment to identify an injury of unknown origin, which resulted in a large bruise across her chest and breasts. The injury was not promptly identified or reported by staff, and skin assessments failed to document the presence of new bruising. Interviews revealed inconsistencies in staff recollection of events and a lack of thorough skin assessments, with some staff only assessing visible areas and not the entire body. The resident's representative and hospice staff provided photographic evidence of extensive bruising, which was not documented in the facility's records. There was also confusion among staff regarding the use of mechanical lifts and the circumstances surrounding the injury. The facility's documentation practices did not reflect the care and treatment provided, and there were discrepancies in medication administration records and narcotic counts. Staff interviews indicated a lack of awareness and communication regarding the residents' conditions and care needs. The failures in care and documentation placed residents at risk for harm, including starvation, uncontrolled pain, and unidentified injuries.