Failure to Follow Physician Orders for Weights, Wound Care, and Medication Administration
Penalty
Summary
The facility failed to obtain and document resident weights as ordered for two residents. One resident with dementia and a risk for unintentional weight loss had a physician's order for weekly weights, but weights were not obtained on several specified dates. Another resident with diagnoses including CHF and diabetes had a physician's order for daily weights with instructions to notify the physician if there was a significant weight gain. Multiple daily weights were missing from the medication administration record (MAR) over two months, and documentation of refusals was only added after the issue was brought to management's attention. The care plan for this resident was also updated after the deficiency was identified. A newly admitted resident with a recent below-the-knee amputation (BKA) did not have physician's orders in place for wound care upon admission, despite hospital discharge instructions specifying daily dressing changes. The resident and his wife reported ongoing bleeding from the surgical site, and observations confirmed a soiled dressing and blood-stained sheets. No dressing changes or wound treatments were documented over the weekend following admission, and a physician's order for wound care was not entered until several days later. The facility's policy required obtaining and transcribing physician orders upon admission, which was not followed in this case. The facility also failed to follow physician's orders for the application and removal of a transdermal nitroglycerin patch for a resident with Alzheimer's disease, hypertension, and heart failure. The resident was found at the hospital with two nitroglycerin patches, one of which was expired, despite an order specifying the patch should be on for 12 hours during the day and off for 12 hours at night. Documentation did not indicate that the physician was notified of the error, and the resident's care plan lacked person-centered interventions related to heart failure and nitroglycerin use. The facility did not have a specific policy for this medication, but the expectation was to follow physician's orders and update care plans as needed.