Failure to Follow Physician Orders and Provide Proper Assessment and Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for four residents. For one resident with heart failure and chronic respiratory failure, staff did not follow a physician's order requiring the head of bed to remain elevated due to shortness of breath. The resident was observed lying flat in bed on two occasions, and a registered nurse confirmed this was not in accordance with the order. Another resident with vascular dementia and diabetes experienced new or worsening edema after a hospital visit, with orders for daily diuretic therapy. Despite this, the facility did not assess or monitor the resident's edema, as confirmed by the Director of Nursing, who acknowledged the lack of documentation for daily weights, lung sounds, vital signs, or edema assessment since the resident's return from the hospital. A third resident with a long-term indwelling Foley catheter developed a significant penile injury, described as a split extending the length of the penis head. The catheter was not consistently secured with a device, and there was no documentation of resident refusal, education, or interventions to prevent catheter-related injury. The care plan lacked interventions for catheter care or securement, and staff interviews revealed inconsistent use of securing devices. Additionally, a fourth resident admitted with abdominal wounds did not receive wound care orders as specified in hospital discharge instructions. The required negative pressure wound therapy and specific dressing changes were not implemented or documented, and nursing staff could not confirm what treatments were provided prior to the resident's transfer back to the hospital.
Plan Of Correction
F684 – Quality of Care Element #1 R20: Physician orders were reviewed and reconciled. Orders were implemented as appropriate. R11: A head-to-toe assessment was completed, and the resident's edema was evaluated and documented. The care plan was updated, and physician notification occurred as necessary. R38: The urinary catheter was properly secured. R67: Wound care orders were implemented, and a complete skin assessment was completed. Element #2: The Director of Nursing and/or designee conducted an audit of residents newly admitted within the last 30 days, residents with physician orders involving wound care, indwelling catheters, or fluid retention diagnoses. Each resident was reviewed for missed orders, unaddressed edema, improper catheter care, and delayed implementation of hospital orders. Element #3: The policies on Admission Orders and Catheter Care were reviewed by the Administrator and revised as necessary. Licensed Nurses and Department Managers were provided education on the aforementioned policies to ensure compliance with orders. Element #4: The Director of Nursing or designee will conduct weekly audits of 10 randomly selected charts for 12 weeks to ensure appropriate orders are in place and being followed per resident record. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025