Failure to Ensure Physician Orders and Monitoring for Medical Devices and Anticoagulation Side Effects
Penalty
Summary
Two deficiencies were identified involving the failure to provide appropriate treatment and care according to physician orders, resident preferences, and goals. In the first case, a resident with a complex medical history, including pleural effusion, acute respiratory distress, metastatic ovarian cancer, and a recently placed Pleurx chest tube and PICC line, was admitted to the facility. Despite clear hospital discharge instructions for daily drainage and care of the chest tube, there were no physician orders entered for the care of the chest tube or PICC line. Additionally, no baseline care plan was developed for these devices. Multiple staff interviews revealed confusion and lack of clarity regarding who was responsible for entering such orders and developing care plans, with staff indicating that orders for the chest tube and PICC line were not transcribed and that the process for entering non-medication orders was not consistently followed. In the second case, another resident with diagnoses including permanent atrial fibrillation and on anticoagulation therapy experienced nine documented bowel movements that were either bright red or tarry black in color, as recorded by CNA staff. These findings were not documented in nursing progress notes, nor was the physician notified, despite the resident's care plan specifically requiring monitoring for bleeding and immediate physician notification of side effects related to blood thinners. Interviews with nursing staff revealed that CNAs reported the findings to nurses, but the information was not assessed or escalated. Further, nursing and supervisory staff stated that they did not routinely review CNA documentation for such changes, and the advanced practice nurse prescriber was not made aware of the repeated abnormal findings. The facility's own policy required that changes in a resident's condition or treatment be immediately communicated to the resident, their representative, and the attending physician, with documentation of the notification and any new orders in the medical record. In both cases, the facility failed to follow its policy and professional standards of practice, resulting in a lack of appropriate assessment, documentation, and physician notification for significant changes in condition and care needs.