Failure to Implement Physician Orders for Resident's Immediate Care
Summary
The facility failed to have physician orders for a resident's immediate care upon admission, specifically for wearing a knee brace and maintaining a non-weight bearing status on the right knee. The resident, an elderly female with a history of dementia, anxiety, and chronic obstructive pulmonary disease, was readmitted to the facility with a nondisplaced tibial plateau fracture and possible compression fractures to the spine. Despite the ER discharge instructions indicating the need for a knee brace and non-weight bearing status, these orders were not entered into the electronic health record by the attending nurse, LVN B, upon the resident's return from the ER. LVN B admitted to not thoroughly reviewing the ER discharge paperwork, which led to the omission of critical care instructions. The Director of Nursing (DON) and the Administrator confirmed that it was the responsibility of the nurse on duty to input these orders into the electronic health record. The DON also stated that she reviews admissions and ER records during weekdays, while the weekend RN is responsible for this task over the weekend. However, in this case, the necessary orders were not communicated or entered, resulting in the resident not receiving the appropriate care. Interviews with the staff revealed a breakdown in communication and procedural adherence. LVN A, who received the initial call from the ER, was unaware of the specific orders, and LVN B failed to input the orders into the system. The DON emphasized the importance of reviewing ER records for new orders and diagnoses to ensure proper treatment plans. The Administrator reiterated that charge nurses are expected to follow physician's orders to provide the required care for residents. This lapse in procedure placed the resident at risk for not receiving appropriate care and treatment.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple chronic conditions and an indwelling Foley catheter did not have physician orders in place for the catheter at admission. Medical records, nursing notes, and the care plan lacked documentation of the catheter order, although CNA documentation confirmed care was provided and surveyors observed the catheter in use. The DON confirmed the absence of physician orders, and the facility lacked a related policy.
A resident with critical illness myopathy and moderate cognitive impairment was readmitted from the hospital without physician notification or medication and treatment orders in place. Staff, including an LPN, confirmed they lacked the necessary orders to provide proper care, and both the medical director and nurse practitioner were not informed of the readmission. The DON acknowledged the orders were not transcribed as required.
A resident with a surgical incision was admitted without proper orders for incision care, leading to a delay in treatment. The hospital recommended washing the incision twice daily, but the facility did not initiate this care until several days later. The ADON confirmed the oversight in obtaining necessary orders upon admission.
Lack of Physician Orders for Indwelling Foley Catheter
Penalty
Summary
The facility failed to ensure that physician orders were in place for a resident with an indwelling Foley catheter at the time of admission. The resident, who was admitted with multiple diagnoses including atrial fibrillation, congestive heart failure, liver cirrhosis, diabetes mellitus type 2, and chronic kidney disease with dialysis, was cognitively intact and required significant assistance with activities of daily living. Medical record review showed no physician orders for the Foley catheter, and there was no documentation in the nursing progress notes or plan of care regarding the catheter. Certified Nursing Assistant documentation confirmed care was provided for the catheter, and observations during the survey verified the presence of the indwelling Foley catheter. The Director of Nursing confirmed the absence of physician orders, and the facility did not have a policy related to physician orders for indwelling Foley catheters.
Failure to Notify Physician and Obtain Orders on Resident Readmission
Penalty
Summary
Licensed nursing staff failed to notify the physician of a resident's readmission and did not obtain medication or treatment orders to guide care for the resident upon return from the hospital. The resident, who had a diagnosis of critical illness myopathy and moderate cognitive impairment, was readmitted to the facility, but there was no evidence in the medical record that physician orders for medications or treatments were in place on the date of readmission. Staff interviews confirmed that the LPN working on the unit at the time did not have any orders to properly care for the resident and did not notify the provider of the resident's return. Further interviews revealed that both the medical director and nurse practitioner were not informed of the resident's readmission, and the director of nursing acknowledged that there was no reason for the failure to transcribe or enter the necessary orders. The administrator stated that it was expected for all orders to be entered and the provider notified immediately upon admission or readmission, but this did not occur in this instance.
Failure to Obtain Admission Orders for Surgical Incision Care
Penalty
Summary
The facility failed to ensure that admission orders were obtained for a resident with a surgical incision, which led to a deficiency in providing appropriate care and treatment. Resident #178, who was admitted with a surgical incision on the neck, did not have any orders in place to wash the incision as recommended by the hospital from which they were discharged. The hospital record indicated that the incision should be washed twice daily with soap and water, but this was not initiated until several days after the resident's admission. Upon observation, it was noted that the resident had clear tape covering the incision, and the resident reported that no treatments had been performed on it by the facility. The physician orders for the month did not include any instructions for incision care until an order was finally placed to wash the incision every shift. The Assistant Director of Nursing confirmed that there should have been an order in place upon admission to cleanse the surgical incision, which was not done, resulting in a lapse in care.
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