Failure to Provide Care According to Physician Orders and Resident Needs
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for two residents. One resident, admitted with diagnoses including high blood pressure, PTSD, and orthopedic aftercare, was observed wearing knee immobilizer braces on both legs. However, there was no physician's order or care plan documented for the use and management of the knee immobilizer. The Therapy Director stated that the resident was required to wear the immobilizers at all times except during bed rest for skin checks and showering, but this protocol was not supported by any documented order or care plan. The Director of Nursing confirmed the absence of these required documents. Another resident, admitted with diagnoses such as cerebral aneurysm, hypertension, and muscle weakness, had physician orders indicating an NPO (nothing by mouth) status and specific oral medications to be administered. Despite these orders, the Director of Nursing confirmed that the physician's orders were not followed as required. These findings demonstrate that the facility did not ensure residents received care and treatment in accordance with physician directives and established care policies.