Failure to Provide Scheduled Care and Services per Orders and Resident Preferences
Penalty
Summary
The facility failed to provide scheduled care and services according to physician orders and resident preferences for two residents reviewed for quality of care. One resident, admitted with a fractured femur and legal blindness, required extensive assistance with activities of daily living (ADLs) and was assessed as moderately cognitively impaired. Orders specified that weights should be obtained weekly for four weeks, but documentation showed that weights were not recorded until nearly two weeks after admission, with only one additional weight recorded before discharge, revealing a 10-pound loss. The resident's care plan, completed two days before discharge, did not address care needs such as bathing, obtaining weights, or instructions for staff regarding refusals of care, despite the resident being at nutritional risk due to multiple co-morbidities. No documentation was provided regarding showers or bathing during the resident's stay. Another resident, who was cognitively intact and required extensive assistance with ADLs, had a care plan indicating a bath should be provided twice weekly and as needed, with a sponge bath as an alternative if a full bath or shower could not be tolerated. The care plan lacked directions for staff on how to handle refusals. Documentation showed inconsistent bathing records, with some days marked as "not applicable" and others as "refused," and only one shower documented during the review period. Orders for weekly weights were not consistently followed, with only three weights documented and no further records. Staff interviews revealed a lack of awareness regarding the functionality of the wheelchair scale and uncertainty about documentation practices for showers and baths. The administrator confirmed that care plans should reflect personalized care needs, including interventions for refusals, but these were not present.