Failure to Follow Therapy Orders and Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for two residents. For one resident, surveyors observed multiple instances where the resident was lying in bed with their feet in a plantarflexed position, without the required support devices such as boots or splints, despite active medical orders for continuous offloading of heels and regular turning and repositioning every two hours. Therapy staff confirmed that the resident was not seen at the prescribed frequency of five times per week for physical therapy, and there was no documented reason for the missed sessions. Documentation for turning, repositioning, and floating heels was also found to be inconsistent, with several missed entries in the point of care records for the month reviewed. For another resident, the facility failed to ensure proper monitoring for side effects of psychotropic medications. The resident had active orders for two psychotropic medications and a specific order requiring every-shift documentation of whether the resident was free from side effects, with instructions to document any side effects in the progress notes. Review of the medication administration record revealed that this monitoring was not documented for 38 out of 40 shifts over a two-week period, and there were no progress notes indicating side effects or their absence. The DON confirmed that the required documentation was missing and acknowledged that nurses may have misinterpreted the order. These deficiencies were identified through direct observation, interviews with staff, and review of medical records and documentation. The failures included not following therapy recommendations and medical orders for positioning and support devices, as well as not completing required monitoring and documentation for psychotropic medication side effects.