Failure to Follow Physician Orders and Communicate Therapy Needs
Penalty
Summary
The facility failed to follow a physician's order and did not implement a system to ensure that required treatments or procedures needing a physician's order were carried out for one resident. The resident in question had multiple complex medical diagnoses, including hypertension, syphilis, gastrostomy, asthma, COPD, heart failure, use of anticoagulants, epilepsy, HIV, pulmonary embolism, ventricular tachycardia, polyneuropathy, dysphagia, adjustment disorder, vascular dementia, sepsis, hypoxemia, and hypotension. The resident was cognitively impaired, as indicated by a BIMS score of 00, and had a history of receiving physical and occupational therapy, with the last documented therapy sessions occurring nearly a year prior to the events described in the report. Despite a physician's order dated for physical and occupational therapy evaluation and treatment, there were no documented therapy notes or evaluations corresponding to this order. The resident's family and a nurse from a requested rehabilitation facility repeatedly sought updated therapy evaluations to facilitate a transfer and insurance approval, but these were not provided in a timely manner. Multiple staff interviews revealed confusion and lack of communication regarding the need for new therapy evaluations, with some staff unaware of the family's request and others unsure of the process for obtaining the necessary physician orders. The facility did not have a policy on effective communication or timely notification for obtaining physician orders, and there was a breakdown in communication among staff, including the social service director, certified nurse assistant, and resident care coordinator. This led to significant delays in obtaining the required therapy evaluations, which were necessary for the resident's transfer to another facility and for insurance processing. The deficiency was identified through interviews, record reviews, and observations, highlighting the facility's failure to ensure physician orders were followed and communicated appropriately.