Failure to Follow Physician Orders and Assessment Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for several residents. In one instance, a resident who experienced a fall in the bathroom was assisted off the floor and placed in a wheelchair by CNAs before a nurse was notified or an assessment was performed. The Director of Nursing confirmed that facility policy requires a nurse to assess a resident before moving them after a fall, and follow-up assessments were not documented in the medical record for the required period following the incident. The resident later complained of increased pain, and an X-ray revealed an acute fracture, indicating that the necessary post-fall monitoring and documentation were not completed as per policy. Another resident returned from a podiatry appointment with ace wraps applied to both lower extremities for edema control, but the new order for ace wraps was not entered into the facility’s electronic system. The resident reported that nursing staff did not reapply the ace wraps after dressing changes, and the wound care nurse confirmed that the order was not entered due to a communication issue. The Director of Nursing stated that it is the floor nurse’s responsibility to enter new orders from outside appointments, but this was not done, resulting in the resident not receiving the prescribed treatment. Additional deficiencies included a resident with a cervical vertebral fracture who was ordered to wear a soft cervical collar at all times, but was observed without the collar secured during care, leading to complaints of neck pain during repositioning. Another resident’s medication order for mirtazapine was not properly clarified upon admission, resulting in the medication being discontinued for several weeks despite ongoing indications for its use. The facility’s policy requires clarification of medication orders, especially when stop dates are unclear, but this was not followed, leading to an interruption in the resident’s prescribed medication regimen.