Failure to Follow Physician's Orders for Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident received care and treatment in accordance with professional standards of practice by not following a physician's order to send the resident to the hospital. The resident, who had Crohn's disease, diabetes, and hemiplegia, was assessed by a registered nurse after a family member expressed concern that the resident might be having a stroke. Although the resident was awake, alert, and oriented, the physician was contacted and gave an order to send the resident to the hospital. However, the order was not documented in the electronic medical record, and the resident was not sent to the hospital as instructed. Interviews with staff revealed a breakdown in communication and decision-making. The Director of Nursing assessed the resident and decided not to send her to the hospital, contrary to the physician's order. The registered nurse, who was new to the facility, did not document the order because the Director of Nursing instructed otherwise. This led to a failure in executing the physician's directive, as the resident's family was informed that the resident would be sent to the hospital, but this did not occur. The incident highlights a lapse in following professional standards and physician orders, resulting in a deficiency in the care provided to the resident.
Plan Of Correction
1. Resident 2 no longer resides in the facility. 2. Residents that have a change in condition will have a full assessment completed by the Registered Nurse with documentation in the medical record. The Registered Nurse will immediately call the physician informing him of the assessment and the change in condition. The Registered Nurse will then implement orders received and update the resident's representative of orders. 3. The Director of Nursing and the Registered Nurses will be educated by the facility Consultant/Designee on assessing residents with change of conditions and following the physician's orders, along with implementing physician's orders, updating resident's representatives, and completing documentation in the medical record. 4. An audit will be completed by the facility consultant/Designee on any resident with a change of condition to ensure a complete assessment was performed, with physician notification, orders implemented, complete documentation in the medical record, and resident representative updated. This audit will be completed daily 5 times a week for two weeks, then three times a week for two weeks, then weekly for two weeks, then monthly for two months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met. 5. The completion date will be 02/11/2025.