Failure to Implement Resident-Directed Care and Treatment per Professional Standards
Penalty
Summary
The facility failed to provide resident-directed care and treatment consistent with professional standards of practice for one resident. A verbal physician's order was entered into the clinical record for a staff member to be present with the resident during meals, and for the resident to take small bites and sips. However, there was no evidence that this order was based on a conversation with the practitioner, nor was it supported by recommendations from Speech Therapy or included in the hospital discharge orders. The DON confirmed that the order was entered in error and not based on appropriate consultation. Observations revealed that the resident was left alone during meals, feeding themselves without staff supervision, contrary to the order in the clinical record. The DON confirmed that staff did not follow the order for supervision during meals. The resident's diagnoses included respiratory failure, pneumonia, difficulty swallowing, an artificial right knee, and altered mental status. The failure to implement care according to orders and professional standards was confirmed through record review, staff interview, and direct observation.