Failure to Follow Physician Orders and Accurately Document Care
Penalty
Summary
The facility failed to ensure that physician orders were followed for three residents, resulting in a deficiency under the Quality of Care regulation. For one resident, there was an active physician order for anti-embolic stockings to be worn during the day and removed at night. Observations on multiple occasions showed the resident was not wearing the stockings, and both the resident and her private duty aide confirmed that the stockings were not applied. Nursing staff documented in the Medication Administration Record (MAR) that the stockings were applied, but later admitted they were unsure if this was accurate and had not verified their application. The Director of Nursing (DON) confirmed that private duty aides are not responsible for applying the stockings and that refusals or non-application should be documented, which was not done in this case. Another resident had an active order for high compression stockings to be worn on both legs every shift. Observations revealed the resident was not wearing the stockings, and the resident stated he had not been asked to wear them since admission. Nursing staff documented in the MAR that the stockings were applied, but admitted this was not the case and that no stockings were present in the resident's room. The DON acknowledged that the medical record was inaccurate and that staff should not document treatments that were not completed. A third resident had a physician order for a specific laboratory test to be drawn in the morning. The facility failed to obtain the ordered lab test at the specified time, and there was no documentation in the medical record explaining why the test was not performed as ordered. The DON confirmed that the order was not followed and that the expectation is for nurses to document reasons when physician orders cannot be carried out.
Plan Of Correction
Resident #13 had order for discontinued on. Resident #133 had physician order reviewed and placed on resident for remainder of his stay. Resident discharged on. Resident #29 had lab order incorrectly entered on level drawn on, and results required no change in orders. Education provided to licensed nurses and ARNPs on staff responsibility of resident to receive treatment and care in accordance with professional standards of practice in regards to following physician orders with and lab orders. Audit other physician orders for and labs to ensure professional standards of practice are being followed. Audits to be conducted to ensure compliance with professional standards of practice by DON/designee of physician orders for and labs daily for four weeks, and three times a week for eight weeks thereafter. Results to be taken to monthly QAPI meeting for three months. And ARNPs on staff responsibility of resident to receive treatment and care in accordance with professional standards of practice in regards to following physician orders with and lab orders. Audit other physician orders for and labs to ensure professional standards of practice are being followed. Audits to be conducted to ensure compliance with professional standards of practice by DON/designee of physician orders for and labs daily for four weeks, and three times a week for eight weeks thereafter. Results to be taken to monthly QAPI meeting for three months. F 684 Treatment that was not completed, including the. If the resident refuses a treatment or the, the nurse should document the refusal in the medical record and notify the physician. On at 9:58 a.m., the DON said private duty sitters do not apply for the residents. Review of the medical revealed Resident #133 was admitted on. Diagnoses included aftercare following, replacement and left with a history of atherosclerotic. Review of the physician's orders revealed an active order dated at 7:00 p.m. for "high both every shift." Review of the MAR for revealed the nurses documented the were applied on and. Review of Resident #113's medical record did not contain information that the resident refused the. On at 12:17 p.m., observed Resident #133 in the room wearing shorts. There were no applied to the. The resident said he does not wear and no one asked him to wear them. He said he came to the facility with an Wrap for the left but it was removed the next morning and there has been nothing else for the since then. The original surgical was observed to the left. On at 10:12 a.m., observed Resident. F 684