Failure to Assess, Notify, and Follow Advance Directives and Physician Orders
Penalty
Summary
The facility failed to ensure timely assessment and physician notification following acute changes in a resident's condition, did not follow the resident's advance directives for hospital transfer, and did not consistently follow physician orders for medication administration. The resident, who had a history of congestive heart failure, syncope, hypomagnesemia, and muscle weakness, was admitted for rehabilitation with the goal of returning home. Her POST form indicated she wished for full interventions, including hospital transfer and intensive care, if needed. Despite this, there were multiple instances where significant changes in her condition, such as unrelieved pain, low blood pressure, dehydration, difficulty breathing, anxiety, restlessness, and vomiting, were not promptly communicated to the physician, nurse practitioner, or family. Documentation in the resident's medical record was inconsistent regarding the administration and holding of her magnesium supplement, which was ordered to be held due to diarrhea but continued to be administered on several days. The Medication Administration Record (MAR) did not consistently reflect the reasons for holding or administering the supplement, and there was a lack of documentation supporting the clinical decisions made. Additionally, the resident's family was not promptly notified of her acute decline, and her wishes for hospital transfer were not immediately honored when her condition worsened. Staff communication with the family was inconsistent, and the family reported confusion and distress over the explanations provided and the documentation in the medical record. Interviews with facility staff, the nurse practitioner, and the resident's family revealed that the physician and family were not notified in a timely manner of the resident's significant changes in condition, including unrelieved pain, low blood pressure, dehydration, and acute respiratory distress. The facility's policies required immediate notification of significant changes, but these were not followed. The failure to assess, notify, and act according to the resident's advance directives and physician orders contributed to the deficiency identified by surveyors.