Failure to Notify Physician and Administer Critical Treatments
Penalty
Summary
The facility failed to immediately notify the resident's physician and representative of significant changes in the resident's condition, as well as failures in administering ordered treatments and medications. Specifically, a resident with a history of cerebral infarction, sepsis due to E. coli, end-stage renal disease (ESRD) requiring hemodialysis, multiple pressure ulcers, and a recent hospital stay for sepsis was admitted with orders for IV antibiotics (Zosyn), wound care, and pain management. Upon admission, the facility did not administer the ordered IV antibiotic Zosyn from admission through several days, nor did they notify the physician of this failure. Additionally, wound care orders for the resident's 14 wounds were not entered or implemented in a timely manner, and the physician was not informed of these omissions. The resident also missed a scheduled hemodialysis treatment due to an elevated heart rate, but the physician was not notified of the missed treatment or the change in condition. Documentation and interviews revealed confusion among nursing staff regarding roles and responsibilities for wound care and medication reconciliation, leading to delays in treatment initiation. The resident did not receive any pain medication prior to wound care treatments, and no pain assessments were documented, despite the presence of multiple severe wounds. The only pain medication ordered was oral acetaminophen, which was not administered, and the resident was gastrostomy status, making oral administration inappropriate. Interviews with staff, including the admitting nurse, treatment nurses, DON, and medical director, confirmed a lack of communication and clinical review following the resident's admission. The medical director and nurse practitioners were not informed of missed medications, missed dialysis, or incomplete wound care, and there was no evidence of a care plan for pain management. Observations of wound care procedures showed the resident exhibiting signs of pain without appropriate pain management. These failures were identified as an Immediate Jeopardy situation, as they resulted in the resident being transferred to the hospital with sepsis and ultimately undergoing bilateral above-knee amputations due to necrotic tissue and lack of blood flow.