Failure to Provide Timely Physician-Ordered Services and Documentation
Penalty
Summary
The facility failed to provide necessary care and services to two residents as required by professional standards and facility policy. For one resident, an Infectious Disease physician recommended an urgent MRI of the right hip to assess an abscess. The recommendation was documented during a telemedicine appointment, but there was no evidence that licensed staff reviewed the physician's notes or communicated the recommendation to the ordering physician in a timely manner. Additionally, there was no documentation that arrangements for the urgent MRI were made or scheduled promptly. The MRI was eventually scheduled more than a month after the initial recommendation, and staff interviews confirmed that the process for communication and scheduling was not followed as required. For another resident, there was a physician's order to record intake and output (I&O) every shift for 30 days, with a reassessment after that period. However, a review of the medical record found no documented evidence that the I&O values were recorded as ordered. Multiple staff members, including an LVN, an RN, and the Medical Records Director, verified that the required documentation was missing from the resident's record. Both deficiencies were confirmed through interviews with facility staff, including the Administrator, DON, and other relevant personnel, who acknowledged the lack of documentation and communication. The failures had the potential to affect the well-being of the residents involved, as the necessary care and services were not provided in accordance with physician orders and facility policy.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 85 and 195 was affected by this deficient practice. Resident 195 was no longer in the facility. Resident 85 has scheduled MRI was completed on 7/28/2025 and no negative outcome was noted. On 8/5/2025-8/8/2025, DON in-serviced all licensed nurse about facility policy and procedure when resident coming from an appointment and scheduling any follow-up order such as an MRI to prevent any delay of treatment. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All resident were potentially affected by this deficient practice. RN supervisor and Unit manger audited all residents that came back from an appointment in last 90 days and found no other issue noted with follow up order or plan of care. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. RN supervisor or designee will review all resident's medical record when coming back from an appointment and follow up at medical office to make sure all follow up order or procedure was notated in resident's medical record. DON or designee will review 24-hours and 72-hours summary report during clinical meeting (M-F) to make necessary care and services was being followed-up and plan of care was updated. 4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON and Administrator will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON and Administrator will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025