Failure to Follow Care Plans and Physician Orders for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plans and physician orders were consistently followed for multiple residents, resulting in several deficiencies. For two residents with orders to monitor and document the severity of edema every shift, staff did not record the required information in the medical record. Additionally, for one of these residents, fluid intake was not documented with every meal as ordered, with staff interviews confirming the lack of documentation and a misunderstanding of responsibility between nurses and CNAs. Another resident with severe cognitive impairment had a physician's order and care plan directive to wear a swath and sling on the left arm when not icing or elevating it. Observations over multiple days showed the resident was not wearing the swath and sling, and a hospice CNA reported never having seen or applied the device. Nursing staff confirmed the order was active and should have been followed. Further deficiencies included the failure to complete and document vital signs every shift for a resident with hemiplegia, hypertension, and dementia, despite a standing physician order. Additionally, a resident admitted to hospice services with a documented DNR status did not have corresponding physician orders or care plan updates reflecting code status or hospice admission. The DON confirmed these omissions in both the physician orders and care plan documentation.