Failure to Obtain Wound Care Orders Upon Admission
Summary
The facility failed to obtain physician orders for wound care upon the admission of a resident, identified as Resident 2, who was admitted with multiple medical conditions including sepsis, cellulitis, and Bullous Pemphigoid. The admission records were incomplete, lacking necessary wound care orders for open areas on the resident's chest, upper right arm, abdomen, and both lower legs. This oversight was confirmed during a review of the resident's medical records and interviews with facility staff, including the Director of Nursing (DON) and the Medical Director (MD). Interviews with staff revealed that the admission process was not followed, and there was a lack of communication and documentation regarding the resident's condition. The DON confirmed that no wound assessments or measurements were completed, and the MD acknowledged the issue of incomplete admission orders. Staff members, including a Licensed Nurse and a Registered Nurse, admitted to not performing necessary assessments or obtaining verbal reports, citing busyness and oversight as reasons for the lapse in care. This resulted in a delay in addressing the resident's wound care needs.
Penalty
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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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