Failure to Follow Physician Orders for Fall Prevention and Tube Feeding Care
Penalty
Summary
The facility failed to provide services in accordance with professional standards of practice for two residents. For one resident with severe cognitive impairment and total dependence on staff for self-care and transfers, a physician's order and care plan intervention required a fall mat to be in place at the bedside following a recent fall. However, during observation, the fall mat was not present, and facility staff confirmed it should have been in place as ordered. For another resident who was dependent on staff for all activities of daily living and received nutrition and hydration via PEG tube, the registered dietician recommended, and a physician's order was entered, to increase the water flush from 30ml/hr to 40ml/hr. Despite this, observations on multiple occasions showed the water flush remained set at 30ml/hr. Staff interviews confirmed the order had not been implemented as required, and nursing staff had not verified or adjusted the pump settings to ensure the resident received the prescribed water flush.