Failure to Provide Necessary Care and Treatment According to Orders and Resident Preferences
Penalty
Summary
Three residents did not receive necessary care and treatment as ordered or according to their preferences and goals. One resident with a history of paraplegia and a chronic Foley catheter exhibited symptoms consistent with a urinary tract infection, including cold sweats, shivers, increased lethargy, and hypotension. Although a nurse practitioner ordered a urinalysis with culture, the sample was not processed, and the order was later cancelled by the Director of Nursing, who incorrectly determined the resident did not meet infection criteria. Review of the resident’s history and symptoms indicated that the criteria for catheter-associated urinary tract infection were met, and the urinalysis should not have been cancelled. Additionally, the same resident had a wound culture ordered for an infected wound, but the specimen was improperly stored in the refrigerator, resulting in the lab not processing it. A new specimen was not obtained until several days later, delaying appropriate treatment for the infection. Another resident was admitted with multiple surgical wounds to the left leg following a traumatic injury. Upon admission, there was no comprehensive assessment of the surgical incisions, and the care plan did not specify the locations or details of the wounds. Hospital discharge instructions required daily dressing changes and monitoring for drainage, but there were no corresponding orders or documentation of such care being provided until a week after admission. The first comprehensive wound assessment and appropriate treatment orders were not implemented until several days after admission, resulting in a lack of monitoring and treatment for the surgical wounds during that period. A third resident, who is severely cognitively impaired and dependent for all care, was observed during morning care to have two clean incontinent briefs placed on them by CNAs. Staff interviews revealed that double briefing is only to be done if it is part of the resident’s care plan or at the request of the resident or their representative, and this should be documented. Review of the care plan and Kardex showed no intervention directing staff to double brief this resident, indicating that care was not provided according to the resident’s plan or preferences.