Failure to Follow Physician's Orders for Multiple Residents
Penalty
Summary
The facility failed to follow physician's orders for four residents, as evidenced by clinical record reviews, staff interviews, and direct observations. One resident with a history of a Stage Three pressure injury to the coccyx had a physician's order to be repositioned every two hours to offload the coccyx. However, observations showed the resident remained in a wheelchair for approximately four hours without repositioning, and staff interviews confirmed the order was not followed during this period. Another resident with a broken left hip and a physician's order for no weight bearing on the left leg was observed being transferred in a manner that allowed weight bearing on the affected leg. Staff interviews confirmed that the resident was assisted to stand and hold onto a grab bar, permitting weight bearing contrary to the physician's order. The Director of Nursing also confirmed that the current order required non-weight bearing status, which was not maintained. A third resident with a physician's order for BiPAP therapy at hours of sleep was found to be without the BiPAP machine for several months, as confirmed by both the resident and staff. Additionally, a fourth resident with an order for Active Critical Care 30 ml twice daily for wound healing had multiple missed or undocumented administrations of the treatment, as shown in the Medication Administration Record and confirmed by the Director of Nursing. No facility policy regarding following physician's orders was provided.