Failure to Administer and Document Physician-Ordered Treatment
Penalty
Summary
The facility failed to follow a physician's order for a treatment for one resident, as well as its own policies regarding physician orders and medication administration. Specifically, the treatment and medication ordered by the physician were not administered on several specified dates, as evidenced by blank entries on the Treatment Administration Record (TAR). There was no documentation of the treatment being provided, nor was there any record of the resident refusing the treatment or the physician being notified of missed doses. Interviews with nursing staff confirmed that the expectation is for all treatments to be administered as ordered, with proper documentation on the TAR. Staff stated that a blank on the TAR indicates the treatment was not done, and that refusals or missed treatments should be documented, with the physician notified as appropriate. The facility's policies require that all treatments and medications be documented, and that any medication not given, including refusals, must be recorded with the reason and physician notification as needed. A review of the resident's medical record showed that the required treatment was not administered on multiple occasions, and there was no documentation in the progress notes or TAR to indicate that the physician was notified of these missed treatments. The deficiency was identified for one of eighteen residents reviewed, and the failure to follow physician orders and facility policy was confirmed through record review and staff interviews.
Plan Of Correction
F658 Services Provided Meet Professional Standards ELEMENT 1 The staff caring for Resident #5 on days 7/6, 7/7, 7/20, 7/25, and 7/31/24 were re-educated on physician order and medication administration policies on documentation. Staff was re-educated to follow up with notification to medical provider and document when treatments are not performed. ELEMENT 2 All residents have the potential to be affected by this practice. ELEMENT 3 Leadership staff are educated on use of the Point Click Care dashboard to track missing medication and treatment signatures. Staff are directed by nurse leadership to complete electronic treatment record documentation before the end of shift. ELEMENT 4 Root cause analysis was conducted and a QAPI performance improvement project team formed to address discharge concerns. The Director of Nursing / designee audits numbers of missed documentation monthly. Findings shall be reported to the Licensed Nursing Home Administrator x 3 months. The findings and actions taken will be reported to the QAPI committee for review and further direction as appropriate. Date of Completion: June 9, 2025