Failure to Provide Person-Centered Care and Timely Medical Intervention
Penalty
Summary
The facility failed to provide person-centered care and treatment in accordance with professional standards of practice for two residents. One resident, who lacked decision-making capacity and had multiple chronic conditions including diabetes, chronic kidney disease, and bilateral lower limb amputations, experienced repeated episodes of nausea and vomiting over more than ten days. Despite ongoing symptoms, abnormal laboratory findings, and a decline in oral intake and mental status, the facility did not refer the resident to the hospital for evaluation until a family member insisted. Upon transfer, the resident was diagnosed and treated for acute metabolic encephalopathy, acute kidney injury, aspiration pneumonia, and a urinary tract infection. Another resident, who was alert and oriented, experienced an episode of hypoglycemia after requesting food at night and being denied by a nursing aide, who reportedly told the resident to "shut up and go to sleep" and that there was nothing to eat. The resident later reported this interaction, and it was confirmed that snacks were not available at night as needed for diabetic management. Documentation showed that the facility was aware of the need for bedtime snacks to prevent hypoglycemia, as evidenced by a physician's order, but failed to ensure this was provided. Additionally, the same resident reported a subsequent incident where a nursing assistant refused to provide timely incontinence care, stating that checks were only every two hours, which was corroborated by the resident's roommate. The events leading to the deficiencies included failure to escalate care for a resident with worsening symptoms and abnormal findings, lack of timely and appropriate response to a resident's request for food to manage hypoglycemia, and failure to provide prompt incontinence care. These actions and inactions demonstrate a lack of adherence to person-centered care and professional standards, resulting in unmet care needs and delayed medical intervention.