Failure to Follow Physician Orders for Consults and Wound Care
Penalty
Summary
The facility failed to ensure that two residents received treatment and care in accordance with physician orders. For one resident with a history of Parkinson's disease, rheumatoid arthritis, and chronic kidney disease, there was a physician order for a dermatology consult and treatment for right hand lesions. The dermatologist requested a face sheet and a photograph of the lesions, and later required a signed consent form to schedule a biopsy. However, the consent form was not signed or dated, and there was no documentation that the consent was faxed to the dermatology clinic. There were no follow-up notes in the resident's record for several months, and the resident reported that the facility had not provided any treatment for her skin issue, which had persisted for about six months. Staff interviews confirmed that the required steps for the dermatology consult were not completed, and the resident was not seen by a dermatologist as ordered. Another resident, with diagnoses including type 2 diabetes mellitus, diabetic neuropathy arthropathy, hypertension, and a right above-the-knee amputation, had physician orders for daily wound care and dressing changes to the surgical site. During observation, the resident was found in bed without a dressing on the surgical site. The nurse present was aware that the dressing was missing and acknowledged the importance of keeping the wound covered to prevent infection. Another nurse was not aware that the dressing was missing but also stated the importance of following the physician's order to keep the wound covered. The DON confirmed that the facility must follow physician orders and keep the wound covered to prevent infection. The facility's policies and procedures were reviewed and indicated that residents have the right to quality care, dignity, and respect, including care that honors their goals, choices, and preferences. The policies also state that residents are entitled to equal access to quality care. Despite these policies, the facility did not ensure that the two residents received care in accordance with physician orders, resulting in one resident not receiving a dermatology consult and another resident not having their surgical wound properly dressed.
Plan Of Correction
This plan of correction constitutes the facility's written credible allegation of compliance. Preparation and/or execution of this Plan of Correction does not constitute an admission or agreement by the provider of the truth of the facts alleged, or the conclusion set forth on the Statement of Deficiencies. This plan of correction is prepared and/or executed solely because of the provisions of the health and safety code section 1280 and 42 CFR 483. F-tag 684 I: Corrective Action for residents found to have been affected: • Resident 2 lesion was reassessed by the RN on 5/18/2025. The attending physician was made aware of the dermatology follow-up appointment and orders were given by the physician on 5/20/2025 for a Dermatology consult on June 18, 2025, at 0930. • Resident 28's treatment for right AKA was completed by the RN on 5/18/25. • Resident 28 was reassessed by RN on duty for any signs or symptoms of infection such as drainage, pain, foul smelling odors, etc. Resident 28 wound remains stable at this time. • No other residents have been affected. II: Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • On 06/06/2025, the MRD completed an audit of residents' specialist consult orders in the past 30 days to ensure that residents with orders are seen per physician orders. • The DON/designee performed an audit on 5/18/25 on residents' treatments and verified that treatment orders were followed per physician. III: Facility measures and systemic changes to ensure the deficient practice does not recur: • DON/designee conducted an in-service to facility licensed nurses regarding following physician orders for treatment, including follow-up of needed consult orders of residents as ordered by the physician. The goal is to ensure that residents receive treatment and needed services per the physician's order. • MRD will conduct audits that residents' consult orders are followed per physician orders weekly for 1 month then bi-monthly for 2 months. • DON/designee will conduct random audits of 5 residents' treatments weekly for orders to ensure that each order is followed by physician orders X 90 days. IV: Facility's plan to monitor corrective actions, achieve, and sustain compliance: • Integrate the POC into the QA Process. • The Medical Record Director/designee will report on the findings and trends of weekly audits of new psychotropic medications for informed consent during the monthly QA meeting for the next 3 months to ensure compliance. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V: Corrective Action Completion Date: 6/12/2025