Failure to Implement Provider Orders and Follow-Up Care
Penalty
Summary
The facility failed to carry out provider orders for multiple residents, as evidenced by missed laboratory draws, failure to administer medications as ordered, and lack of follow-up on diagnostic procedures. For several residents with chronic and acute conditions such as diabetes, heart failure, seizure disorders, and recent fractures, provider orders for routine and as-needed labs, medication administration, and specialist follow-up were not implemented as directed. In many cases, the orders were either not transcribed correctly onto the Medication Administration Record (MAR), were signed off in error, or were not acted upon at all. For example, residents with orders for routine labs every six months did not have labs collected as scheduled, and residents with orders for as-needed diuretics based on weight gain did not receive the medication when indicated by their weight records. Residents with complex medical needs, including those with recent falls and fractures, did not receive timely follow-up with specialists as ordered. In one instance, a resident who sustained a hip fracture and was discharged from the hospital with orders for orthopedic follow-up did not have the appointment scheduled, and there was no documentation of the follow-up visit. Similarly, another resident with a provider order for a sleep study due to insomnia and related symptoms did not have the study scheduled or completed, despite repeated documentation in clinic notes and nursing progress notes indicating the need for this diagnostic test. The facility's process for handling provider orders was inconsistent and lacked clear accountability. Orders communicated during provider rounds were not always transcribed or implemented, and dictated clinic notes containing new orders were not systematically reviewed or acknowledged by nursing staff. The facility's reliance on agency staff and frequent staff changes contributed to lapses in communication and follow-through. The facility's own policy required that provider orders be clearly documented, transcribed, and implemented, but this was not consistently followed, resulting in missed care interventions for multiple residents.