Failure to Provide Care per Physician Orders and Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for three residents. For one resident with diabetes, there were multiple instances of significantly elevated blood glucose levels, as documented in the clinical record, but there was no evidence that the physician was notified as required by the sliding scale insulin order. The Director of Nursing confirmed that the facility did not document physician notification for these high blood glucose readings, indicating a failure to follow the prescribed protocol for managing hyperglycemia. Another resident with a history of constipation and on scheduled narcotics did not receive bowel management interventions as outlined in the facility's bowel protocol. Despite several days without a bowel movement, the medication administration record did not show that the required medications were given according to the protocol. Staff interviews confirmed that the bowel protocol should have been initiated and that the clinical record would alert staff to the need for intervention, but this was not done in a timely manner for this resident. A third resident with a wound vac for a pressure ulcer had physician orders for wound vac management but did not have orders for an alternative dressing method, such as wet-to-dry, in the event the wound vac became inoperable. Staff confirmed that there was no such order in place. The lack of an alternative treatment order meant that appropriate care could not be ensured if the wound vac failed, as required by the resident's care plan and physician orders.