Failure to Follow Physician Orders for Lab Monitoring and Oxygen Therapy
Penalty
Summary
The facility failed to follow physician's orders and ensure appropriate monitoring and documentation for two residents. For one resident with chronic obstructive pulmonary disease, major depressive disorder with psychotic features, and dementia, the facility did not obtain a required valproic acid level after the initiation of Depakote, despite a physician's order and pharmacy recommendation. Documentation in the medical record indicated the lab was completed, but interviews and record review confirmed that no specimen was collected and no lab result was available. The APRN who ordered the lab was unable to locate any evidence of the result and acknowledged uncertainty about why documentation indicated the lab had been reviewed. For another resident with congestive heart failure and dementia, the facility failed to obtain a physician's order for oxygen therapy following a hospitalization for respiratory failure, sepsis, and pneumonia. Although the hospital discharge summary recommended continued oxygen therapy with specific parameters, the admission orders did not include oxygen. Nursing notes showed the resident continued to receive oxygen without a corresponding physician's order, and the APRN later acknowledged the omission was an oversight. Documentation errors also occurred, with a progress note incorrectly stating the resident no longer required oxygen, despite ongoing administration. Facility policies required that all services, including medication administration and lab monitoring, be documented accurately and that orders for treatments such as oxygen specify rate, flow, route, and rationale. The failures in both cases were confirmed through interviews with nursing and APRN staff, review of clinical records, and facility documentation, demonstrating a lack of adherence to physician orders and facility policy regarding medication and treatment management.