Failure to Follow Physician Orders and Monitor Changes in Condition
Penalty
Summary
The facility failed to follow physician orders, complete assessments, monitor or implement appropriate interventions, and recognize changes in condition for multiple residents, resulting in significant harm. For one resident with complex respiratory and cardiac conditions, staff did not obtain daily weights as ordered, failed to monitor for fluid retention, and did not consistently follow oxygen therapy orders. The resident experienced labored breathing and a significant weight gain, which was not identified or reported to the provider in a timely manner. Staff interviews revealed confusion and lack of a reliable system for obtaining and documenting daily weights, and the nurse practitioner was unable to assess the effectiveness of diuretic therapy due to missing weight data. Oxygen orders were not entered into the electronic medical record until several days after admission, and staff administered oxygen at incorrect settings based on resident or staff preference rather than physician orders. Another resident with a nephrostomy and history of kidney infections was not properly monitored for changes in urine output or color. Staff failed to document or notify the provider when dark red urine was observed in the nephrostomy bag over several days, and there was no documentation of an episode of unresponsiveness and lethargy. The resident was ultimately sent to the emergency room for evaluation and treatment of a kidney and bladder infection after the nurse practitioner observed the abnormal urine. Staff interviews indicated a lack of training on nephrostomy care and inconsistent documentation and communication regarding changes in condition. A third resident with an indwelling catheter and history of urinary retention and uropathy was not properly monitored for signs of infection. Staff observed blood in the catheter bag but did not document the finding or notify the provider, and the nurse practitioner was unaware of the change until after the resident was sent to the emergency room and diagnosed with a urinary tract infection. Additional deficiencies were identified in the care of a resident with cardiac conditions, where staff failed to monitor blood pressure before administering cardiac medications, did not complete full sets of vital signs after falls, and did not promptly notify the provider of significant changes in condition, including multiple episodes of hypotension and falls. Staff interviews revealed gaps in knowledge regarding monitoring protocols and documentation requirements.
Removal Plan
- Provided re-education and competency testing to licensed nursing staff on the facility's policies/procedures pertaining to change of condition, notification of changes, physician's orders, congestive heart failure, nephrostomy, COPD and catheters to include standards of documentation.
- Developed and implemented an auditing system for monitoring.