Failure to Implement Physician Orders for Pre-Surgical Medication Hold and Back Brace Use
Penalty
Summary
The facility failed to implement and follow physician orders for two residents, resulting in deficiencies in care. For one resident with dementia, Alzheimer's disease, and atrial fibrillation on anticoagulation therapy, the facility did not hold the prescribed blood-thinning medication as instructed in pre-surgical orders faxed by the resident's surgeon. The pre-op instructions, which required holding the medication for three days prior to scheduled abdominal hernia surgery, were faxed to the facility but not acted upon. The resident continued to receive the medication, leading to the surgery being rescheduled. Documentation and interviews confirmed that the facility received the faxed orders but failed to implement them in a timely manner. Another resident admitted with compression fractures of the spine had a physician order to wear a back brace when out of bed. Despite this order being present in the resident's records, observations on multiple occasions showed the resident seated in a recliner without the back brace. Staff interviews confirmed awareness of the order, but the brace was not applied as required. The facility's procedures for handling consulting physician orders were not followed, resulting in the resident not receiving the prescribed treatment.