Failure to Follow Physician Orders and Maintain Professional Documentation Standards
Penalty
Summary
The facility failed to implement and document physician-ordered wound and skin care for a resident admitted after a surgical amputation and with an identified pressure ulcer. The resident was admitted with 22 staples to the amputated toe site and a heel wound, but no wound care orders were entered for either site during the resident's month-long stay. Although the wound care nurse documented weekly measurements and care for the heel, there was no formal order or documentation system in place for staff to consistently sign off on completed treatments. The Director of Nursing was unaware of these omissions until notified by surveyors. Another resident with a history of cerebrovascular disease had a physician's order for daily application and removal of Thrombo-Embolic Deterrent Stockings (TEDS), but was repeatedly observed not wearing them. There was no documentation of refusal or physician notification regarding the lack of TEDS application, and staff could not provide supporting documentation for these omissions. Additionally, a resident with an order for clonidine to be administered via PEG tube with specific blood pressure and heart rate parameters received the medication multiple times when their systolic blood pressure was below the ordered threshold, without documentation that the physician was notified of these out-of-range readings. The facility also failed to maintain professional standards in documenting showers for a resident with an order for showers on specific days. On several occasions, the treatment administration record indicated that the shower was not given, but no reason was documented for the omission. There were also days when the shower order was not documented at all. The Director of Nursing confirmed that staff were expected to document the reason for missed showers and to document all care provided according to orders.