Failure to Follow Physician Orders and Inaccurate Documentation
Penalty
Summary
Surveyors found that the facility failed to follow physician orders for three residents regarding the application of anti-embolic stockings and the timely collection of a laboratory test. For one resident with moderate cognitive impairment and dependent on staff for lower body dressing, there was an active physician order for anti-embolic stockings to be worn during the day. 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 and that no one had instructed them to do so. Nursing staff documented in the Medication Administration Record (MAR) that the stockings were applied, but later admitted uncertainty about whether this was done, and the Director of Nursing (DON) confirmed that private duty aides are not responsible for applying such treatments. Another resident with a history of joint replacement and vascular disease had an active order for anti-embolic stockings to be applied every shift. Observations repeatedly showed 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 during interviews that they had not applied them nor instructed others to do so. The DON acknowledged that the medical record was inaccurate in this regard. A third resident had a physician order for a specific laboratory test to be drawn in the morning, but the test was not obtained as ordered, and there was no documentation in the medical record explaining the omission. The DON confirmed that the order was not followed and that the expected documentation was missing. In all three cases, the facility failed to follow physician orders as prescribed and did not document reasons for non-compliance in the residents' medical records.
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. N 054 N 054 N 054