The required care plan must describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being. This requirement was not met. The plaintiff, as a result of care planning that was not individualized or updated, suffered a decline in pressure ulcers, suffered a urinary tract infection, suffered multiple falls, suffered in pain, and failed to progress in her rehabilitation.
The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete: accurately documented; readily accessible; and systematically organized. This requirement was not met as evidenced by the grossly inadequate documentation in medical records covering plaintiff’s residency. Records were inadequate or completely missing in areas including but not limited to nursing notes, medication administration sheets, treatment administration sheets, weekly skin investigation sheets, and wound assessment sheets. Lack of adequate medical records contributed to increased safety risks, hospitalizations and actual injury for lack of care planning; inaccurate information and lack of communication for and with family and other health care providers; and increase in pain and suffering.
False documentation was noted for one date, when the decedent already had been transfer the previous day.
A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sore from developing. This requirement was not met as evidenced by decedent’s developing an infection in her coccyx pressure ulcer during her residency. The nursing home was cited for deficient practice in this area in February 2010.
The facility must establish and maintain an infection control program. This requirement was not met as evidenced by decedent’s development of a UTI. Decedent, who was incontinent of both bladder and bowel, entered the defendant’s facility without a UTI, and was admitted to the hospital with sepsis from a UTI with possible contribution from a wound infection. This requirement also was not met as evidenced by decedent’s development of a wound infection. Her wound was found to be infected with Proteus mirabilis, bacteria found in the gastrointestinal tract, indicating that the wound was not protected from contamination with feces.
There was also insufficient pain management and no notification of family members of changes to her condition.
It is my considered opinion, rendered within a reasonable degree of nursing certainty, that the staff, as well as the facility’s owners, managers, consultants and agents deviated from the standard of care and failed to adhere to federal and state regulations and state standards of conduct for registered nurses and nursing homes. The lack of care decedent received was outrageous and unacceptable. As a result, decedent was at an increased risk of harm and caused to suffer much unnecessary pain, humility and injuries, including poor wound healing, pain, weight loss, infections, and ultimately death.