Failure to Implement Physician Orders for Two Residents
Penalty
Summary
The facility failed to implement physician orders for two residents, leading to deficiencies in their care. For Resident 52, the facility's consultant optometrist diagnosed significant dry eye syndrome and prescribed artificial tears to be administered twice daily. However, the clinical records showed no evidence that the staff implemented this treatment plan. This was confirmed during an interview with the Nursing Home Administrator, indicating a lapse in following the prescribed care plan for Resident 52. Similarly, for Resident 21, there were physician orders to obtain and document daily weights. The review of Resident 21's weight documentation revealed multiple instances where the staff failed to record the resident's weight on specified dates in January, February, and March 2025. This lack of documentation was also confirmed during an interview with the Nursing Home Administrator, highlighting a failure to adhere to the physician's orders for monitoring Resident 21's weight.
Plan Of Correction
1. Resident 52 was not harmed and physician orders were updated to reflect plan of care. Resident 21 was not harmed and was reviewed. 2. The Director of Nursing reviewed residents physician orders to ensure accuracy. 3. The Director of Nursing educated nursing staff on the importance of issuing physician order in the residents' charts and to follow physician orders for the plan of care for each resident's needs. 4. The Director of Nursing or designee will complete weekly audits for four weeks then monthly for three months to ensure compliance that the physicians orders are being entered and completed for each residents needs. The Director of Nursing will bring audits to the monthly QA meeting for review.