Failure to Follow and Document Physician Orders for Oxygen and Lab Monitoring
Penalty
Summary
The facility failed to follow, document, and/or carry out physician orders for two residents. For one resident with heart failure and severe cognitive impairment, there was a physician order to check oxygen saturation (POx) every shift and to apply oxygen at 2 liters via nasal prongs if the POx was below 90%. Documentation showed that on multiple occasions, the resident's oxygen saturation was below 90%, but there was no corresponding documentation that oxygen was applied as ordered. Staff interviews revealed confusion about the existence of the PRN oxygen order, and staff acknowledged not signing for the administration of oxygen when required. Additionally, there was a lack of nursing assessment documentation on days when low oxygen saturation was recorded. For another resident with diabetes and moderate cognitive impairment, there was a standing order to obtain a Hemoglobin A1c (Hgb A1c) test every six months. Review of the Treatment Administration Records (TARs) and progress notes indicated that the required Hgb A1c tests were not consistently documented as completed according to the order. The only Hgb A1c results found in the records were from a previous year and from a hospitalization, with no evidence that the six-monthly tests were performed as ordered by the physician. Interviews with nursing staff and review of facility procedures revealed that lab orders were supposed to be tracked in a Lab Order Book and on the MAR/TAR, with multiple checks in place to ensure completion. However, the process failed to ensure that the required labs were drawn and documented, and staff were unclear about the status of lab orders and documentation requirements. The facility's policy stated that all medications and treatments should be administered as ordered by a healthcare professional, but this was not followed in these cases.