Failure to Assess and Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to properly assess a resident and follow physician orders regarding timely notification and documentation of a significant change in condition. One resident, admitted with arthritis and cognitively intact, underwent a chest x-ray following a physician's assessment due to respiratory concerns. However, there was no nursing assessment documented regarding the resident's respiratory status or the physical condition that warranted the x-ray. The x-ray results, which indicated pneumonia, were available but not promptly communicated to the physician or acted upon. The resident's condition worsened, with increased cough, abnormal lung sounds, and low oxygen saturation, eventually requiring hospitalization. There were no additional nursing assessments documented prior to the escalation of symptoms and hospital transfer. Another resident, admitted with heart failure and kidney disease, and their family requested a urology appointment during a care conference. Despite this request, staff responsible for scheduling medical appointments did not arrange the appointment, and the request was not followed up on. The staff acknowledged the oversight when interviewed, confirming that the appointment had not been scheduled as requested by the resident and family.