Lack of Physician Orders for Dialysis in Resident's Care Plan
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care, specifically for a resident undergoing dialysis. The resident, who was diagnosed with End Stage Renal Disease and Coronary Artery Disease, did not have documented physician orders for dialysis, including the frequency and monitoring of the permcath. Despite the resident's care plan indicating the need for hemodialysis, there was no evidence of physician orders to support this treatment. Observations and interviews revealed that the resident was alert and oriented, and regularly attended dialysis sessions. However, the facility's documentation did not reflect this, as there were no physician orders in the system for the resident's dialysis schedule. The facility's policy required medication order reconciliation during admissions and routine reviews, but this was not adhered to in the case of the resident's readmission. Interviews with facility staff, including a CNA, RN Manager, and the Director of Nursing, indicated that the omission of the dialysis order was an error during the resident's readmission process. The staff were aware of the resident's dialysis schedule, but the necessary orders were not documented in the system. The Medical Doctor confirmed that the resident was stable and that the omission was likely an oversight during the readmission process.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 F711 Corrective Actions for Residents Identified: Resident # 71 was seen by an attending physician on 12/19/2024. During the visit, the resident's total program of care, including medications and treatments, was reviewed and documented. Resident # 71 received [MEDICAL TREATMENT] without interruption of services; Resident # 71 had an order placed immediately. The Care Plan was initiated on 8/19/2024 and has been reviewed and updated for [MEDICAL TREATMENT]. Element 2 Residents at Risk: All Residents receiving [MEDICAL TREATMENT] have the potential to be affected by this practice. A list of current residents receiving [MEDICAL TREATMENT] in the past three months was obtained, and the Medical Record was audited to ensure that all physician orders [REDACTED]. No Other issues were identified. Audit tool was developed to monitor compliance. Element 3 Systemic Changes: Policy and Procedure for physician's orders [REDACTED]. All Registered Nurses are being educated on the importance of timely physician visits, documentation review, and order accuracy. The nursing supervisor will review care notes weekly to ensure all visits and orders are correctly documented. An audit tool was created to confirm that all physician orders [REDACTED]. Element 4 Quality assurance Monitoring: Conduct weekly audits for 90 days to ensure compliance with physician visits, regulations, care note reviews, and orders. Findings will be reported to the administrator monthly, and any negative findings will be corrected immediately. On a quarterly basis, x 3 quarters ADNS or designee will report findings to the QAPI Committee. QAPI Committee to determine if further action is required. Element 5: Persons Responsible: Completion Date: (MONTH) 12, 2025 Director of Nursing Services: Oversee the P(NAME) implementation and staff education. Medical Director: Collaborate with physicians to ensure timely visits and documentation.