Failure to Provide Timely Assessment, Follow Physician Orders, and Complete Neurological Checks
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and residents' choices for three out of four residents reviewed. In one case, a resident with multiple diagnoses, including chronic respiratory failure, dementia, atrial fibrillation, and anxiety disorder, was receiving anticoagulant therapy and sustained an unwitnessed fall resulting in a head injury and a skin tear. The initial assessment was incomplete, as the nurse practitioner only assessed range of motion and did not return to complete a comprehensive assessment until several hours later. There was no registered nurse assessment documented, and neurological checks were not performed according to policy, with one of the required 30-minute checks missed. When the ambulance arrived, staff were unable to provide a timely and complete report, and the resident was not sent to the hospital until several hours after the fall, despite being on blood thinners and having a head injury. In another instance, the facility did not follow a physician's order to obtain a stool sample to test for Clostridioides difficile for a resident. The order was documented in the treatment administration record, but there was no evidence that the sample was obtained or sent to the lab, nor was there any documentation in the resident's medical record regarding the order. The infection control nurse and nursing home administrator were unaware of the order, and no follow-up was documented. Additionally, the facility failed to complete and document neurological checks for another resident who experienced two unwitnessed falls. The facility's policy required neurological checks to be performed at specific intervals following such events, but there was no documentation that these checks were started or completed. The director of nursing confirmed the absence of documentation, and staff acknowledged that neurological checks should have been performed for unwitnessed falls.