Prisma Health- Lila Doyle in Seneca, SC, has been cited after failing “to ensure resident rights related to choices in treatment,” and failing “to notify the physician and/or family timely of a change in [resident] condition.”
In the first instance of actual harm in this citation, a nurse ignored the resident’s refusal for use of a medication. According to the nurse’s notes, the nurse was explaining the process for inserting a Foley catheter to the resident. The resident told the nurse she was allergic to a medication the nurse was going to use. The nurse checked the physician’s progress notes and told the resident there was no record of her being allergic to this medicine. The nurse “inserted the Foley catheter using a sterile technique,” against the resident’s wishes.
In an interview with the resident, she shared “the nurse said [they] had to put the Foley in [because they] had an order” to do so. The resident told the interviewer, “I didn’t object to the Foley, just the [medication name] they were going to use. I had an allergy to it, so I told her [using it] was against my will.” However, the nurse continued to say they had doctor’s orders to use the medication so they had to, completely disregarding the resident’s concern. Failing to listen to the resident concerning her allergy resulted in great pain for the resident, lasting for days.
The resident told the interviewer, “After the medication was used and the Foley put in, I burned for days and felt like I was swollen in my vagina.”
In the second instance of actual harm in this citation, the nursing home facility did not notify a resident’s physician or family of a major decline in her condition in a timely manor. According to the nurse’s notes, the resident went from being “alert and able to voice needs” to “lethargic and responding to staff but was incontinent and refused breakfast and morning medications,” however no one had been notified. The resident’s family stopped by to visit on the third day and expressed concern about the resident’s condition. Only then did the nurse page the physician to notify them of the resident’s decline.
Further review of the resident’s records showed a SBAR (Situation/Background/Assessment/Request) Assessment Report dated the same day indicating “the resident had decreased consciousness as indicated by the signs/symptoms described as lethargic,” wouldn’t eat or wake up, and was incontinent. According to the report, the family had been notified at 11:00 AM, but the physician had not been notified until the family arrived and expressed concern at 11:22 AM.
The facility’s policy, “Notification of Change,” states that “the facility must immediately inform the resident, consult with the resident’s physician and if known, notify the resident’s legal representative of (sic) interested family member when there is a significant change in the resident’s physical, mental, or psychosocial status.”
The DON (Director of Nursing) later confirmed in an interview that the family had been notified right before they came to visit, and that the resident’s physician had been notified 22 minutes later. The DON did state that a medical professional, such as a NP (Nurse Practitioner) or physician should have been notified much earlier.
When nursing home facilities disregard procedures set in place to provide their residents with the best care possible, they often put their residents in direct danger, whether that be directly (abuse) or indirectly (neglect). In the first incident, staff failed to respect the resident’s rights which resulted in direct harm for that resident. In the second incident, staff failed to follow the facility’s policy and notify the resident’s physician in a timely manner of extreme decline in condition which resulted in indirect neglect. Had the physician been notified earlier, there may have been something more they could do for the patient.
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