In Golden Living Center – Trussville v. Center for Medicare & Medicaid Services, DAB No. CR2634 (September 28, 2012), the nursing home argued that on the “handful of occasions” when the staff missed assessments and treatment would unlikely cause any adverse effect on the resident’s long standing pressure ulcer. The Judge rejected this argument finding that the nursing home chart contained explicit and detailed orders by a physician that was well aware of the resident’s condition and needs and these orders were neglected or ignored by the nursing home staff. The Judge ruled: “If a facility is to meet that obligation [to furnish all necessary treatment and services to that pressure ulcer], then consulting with a resident’s physician, obtaining treatment orders or change in orders, and then following those orders are obvious and indispensable imperatives.”
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