Failure to Assess, Document, and Implement Physician Orders for Resident Care
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice for two residents. For one resident with a history of chronic pain syndrome, right below the knee amputation, and Type 2 diabetes, the facility did not thoroughly assess or document the presence of a spinal cord stimulator implant, which had been previously placed. The resident's admission assessment did not mention the device, and there were no physician orders or care plan interventions addressing the spinal cord stimulator, despite its relevance to the resident's medical condition and pain management needs. The Director of Nursing confirmed that the assessment, physician orders, and care plan failed to address the device as required. For another resident with epilepsy and depression, the facility did not provide nursing care in accordance with physician orders regarding anti-seizure medication administration. The resident was scheduled to receive Levetiracetam at a specific time before leaving for an off-site appointment, as per physician order. However, the medication administration record indicated the medication was given at a time when the resident was not present in the facility, and there was no late entry or progress note to justify this documentation. The resident reported not receiving the medication before leaving, despite requesting it, and subsequently experienced a seizure during the appointment, requiring emergency treatment. Facility policies required accurate transcription and implementation of physician orders, as well as timely and accurate documentation of medication administration. The facility's internal investigation acknowledged a failure to document the medication administration and did not include statements from the resident, her representative, or the accompanying CNA. The Director of Nursing confirmed that staff did not comply with physician orders or documentation standards, resulting in deficiencies in nursing services and medical record-keeping.