Failure to Implement Physician-Ordered Care Plans for Two Residents
Penalty
Summary
The facility failed to implement physician-ordered care plans for two of three sampled residents. For one resident with diagnoses including dependence on renal dialysis, type 2 diabetes mellitus, and chronic fatigue syndrome, the facility did not administer the prescribed antibiotic, Levofloxacin 250 mg, on multiple specified dates as ordered for a urinary tract infection. This omission was confirmed by both the LPN and the Interim DON during interviews, and the missed doses were documented in the resident's Medication Administration Records. Another resident, admitted with conditions such as a sacral pressure ulcer, muscle wasting, spondylosis with myelopathy, wheelchair dependence, and chronic pain syndrome, did not receive wound care as ordered by the physician. Orders included specific wound care regimens for the left hip and sacrum, but review of the Treatment Administration Records showed that wound care was not completed on several dates. The Interim DON acknowledged that the required wound care was not provided on those dates as documented.