Failure to Provide Proper Wound, IV, and Fall Management for Resident with Complex Needs
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for a resident with complex medical needs. The resident, who had a history of sepsis, right femur fracture, dementia, Alzheimer's disease, and recent major surgery, required specialized wound care, IV antibiotics via a PICC line, and was at high risk for falls. Despite these needs, the facility did not ensure that the wound vac was functioning properly, did not have the infected surgical wound assessed by a wound care or attending physician after reports of complications, and failed to document or address issues with the wound vac, even after concerns were raised by the responsible party (RP). The wound vac was frequently dislodged, and there was no evidence of timely follow-up or adjustment to the care plan to address the resident's non-compliance or the device's malfunction. Additionally, the facility did not properly manage the resident's clotted PICC line. When the line became clotted and could not be flushed, IV antibiotics were discontinued and oral antibiotics were started without addressing the compromised central line. There was no documentation of a dressing assessment for the PICC line, and the switch from IV to oral antibiotics was made without clear communication to the RP. The resident missed several doses of prescribed IV antibiotics, and the oral medication provided was not appropriate for her dietary restrictions, as she was on a puree diet and had difficulty swallowing large tablets. The facility also failed to follow fall prevention and post-fall protocols. After an unwitnessed fall, neurochecks were not completed per protocol, and the resident subsequently experienced another fall resulting in a head injury and a left hip fracture. The RP was not notified of major changes in the resident's condition or treatment, including the discontinuation of the wound vac, issues with the PICC line, missed medication doses, and falls. The lack of communication, documentation, and adherence to care protocols contributed to the resident's avoidable decline and multiple complications.