Failure to Provide Ordered MRI and Wound Care Treatments
Penalty
Summary
The facility failed to ensure that a resident received a Magnetic Resonance Imaging (MRI) study as ordered following the identification of a suspicious right adnexal mass on a pelvic ultrasound. The MRI was scheduled on three separate occasions, but there was no documentation in the medical record confirming that the MRI was completed or providing results. Interviews with the DON and nursing staff revealed a lack of awareness regarding whether the MRI was performed or why it was rescheduled multiple times, and the DON was unfamiliar with the facility's documentation policy. The facility's policy requires that the medical record facilitate communication among the interdisciplinary team regarding the resident's condition and response to care, but this was not achieved in this case. Another deficiency involved a resident with a surgical wound on the coccyx, who was admitted with a stage 2 pressure sore that progressed to stage 4 and was later covered by a skin graft. After a hospitalization for unresponsiveness, the resident returned to the facility, but wound care orders were not re-entered until six days after readmission. There was no evidence of any dressing changes during this period, and the wound nurse confirmed that the receiving nurse did not re-enter the wound care orders as required. A third deficiency was identified for a resident with peripheral vascular disease and multiple arterial ulcers, who had physician orders for daily dressing changes to both lower extremities. Observation revealed that the dressings were not changed daily as ordered, with the dressing dates indicating they had not been changed on the required schedule. An LPN verified that the dressings should have been dated for the current day if they had been changed as ordered, confirming the lapse in care.