Failure to Provide Resident-Specific Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide resident-specific care and follow physician orders for two residents, resulting in deficiencies related to quality of care. For one newly admitted resident with diagnoses including dysphagia, functional quadriplegia, and weakness, staff did not initiate appropriate care or document necessary orders for critical aspects such as catheter use, catheter care, oxygen use, respiratory care, and code status. Observations revealed the resident was left in discomfort, unable to access their call light or television, and was not provided with their personal clothing or dentures. Staff were unaware of the resident's needs and failed to follow hospital speech therapy recommendations regarding diet and liquid consistency, resulting in the resident receiving inappropriate meal trays with thin liquids despite a recommendation for thickened liquids. Documentation in the resident's medical record was inconsistent and incomplete, with conflicting information about the resident's catheter size, oxygen use, and level of independence with oral care. Staff interviews revealed a lack of awareness regarding the resident's care needs and orders, with some staff admitting to confusion due to multiple admissions and others not realizing required standing orders were missing. The admitting nurse did not enter necessary orders for the resident's indwelling catheter, oxygen, or code status, and this was not corrected by subsequent shifts. The facility's policies required complete and accurate documentation and timely initiation of care plans and orders, which were not followed in this case. For another resident with congestive heart failure and edema, the facility failed to follow physician orders for daily weight monitoring and notification of significant weight gain. The resident experienced a weight increase of over 6 pounds in 24 hours, but there was no documentation that the physician was notified as required. Additionally, a weight was omitted on a subsequent date, further indicating a lack of adherence to monitoring protocols. These failures demonstrate lapses in following physician orders and ensuring quality of care for residents with complex medical needs.