Failure to Follow Physician Orders and Proper Monitoring Procedures
Penalty
Summary
The facility failed to provide necessary care and services to several residents as ordered by their physicians and as required by their care plans. For two residents with orders to monitor for orthostatic hypotension, the monitoring was not conducted correctly. Specifically, blood pressure (BP) measurements were not taken in all required positions (lying, sitting, standing) within the appropriate time intervals, and the physician's orders did not specify parameters for when to notify the physician of significant BP changes. Staff, including the DON and LVN, were unsure of the correct procedure and lacked facility policies or resources to guide them in monitoring orthostatic hypotension or determining when to notify the physician. Another resident with a physician's order for one-on-one feeding assistance due to aspiration precautions was not provided with the required assistance during meals. Observations and staff interviews confirmed that the resident was eating independently, contrary to the physician's order and the care plan, which specified one-on-one feeding assistance to prevent aspiration. The DON and LVN verified that the order was not being implemented by the facility staff. Additionally, two residents with orders and care plans specifying that blood pressure should not be taken on their left arms due to the presence of dialysis access devices had multiple BP readings documented as being taken from the restricted arm. Facility policy also prohibited BP measurements on the arm with a dialysis access device. Staff interviews and medical record reviews confirmed that these orders were not followed, and the DON acknowledged that BP should not have been taken on the left upper arm for these residents.