Failure to Complete Ordered Guaiac Tests and Report Bruising per Care Plan
Penalty
Summary
The facility failed to ensure that services provided or arranged, as outlined in the comprehensive care plan, met professional standards of quality for a resident with multiple medical conditions, including sepsis, cognitive decline, atherosclerotic heart disease, and dementia. The resident was on aspirin and anticoagulant therapy, with care plan interventions requiring immediate reporting of bruising and other signs of bleeding to the charge nurse and physician. Despite physician orders for three consecutive days of guaiac (fecal occult blood) testing following abnormal lab results indicating low hemoglobin, hematocrit, and red blood cell count, only two tests were completed and documented. The third required test was not found in the resident's medical records, and facility staff were unable to account for its absence. Additionally, the facility failed to report new onset bruising to the physician as directed in both the physician orders and the care plan. The facility's policy required timely notification and documentation of significant changes in resident status, including changes such as bruising, but there was no evidence that this was done. The Director of Nursing confirmed that only two guaiac test results were available and could not explain the missing third test. These failures were identified through interviews and record reviews conducted by surveyors.