Failure to Follow Physician Orders and Inadequate Post-Fall Monitoring
Penalty
Summary
The facility failed to follow physician orders for urine collection for a resident with multiple complex medical conditions, including Multiple Sclerosis and an indwelling urinary catheter. The Family Nurse Practitioner at a urology center ordered a clean catch urine collection for urinalysis and culture a week prior to a scheduled surgery. Although the specimen was collected and sent to the lab, the accompanying paperwork was not completed by facility staff, resulting in the lab being unable to process the specimen. This failure led to the cancellation of the resident's scheduled surgery, as the preoperative requirements were not met. Additionally, the facility did not adequately assess and monitor another resident after unwitnessed falls. Facility policy required neurological and vital sign monitoring at specific intervals following an unwitnessed fall. However, review of the clinical record for a resident with dementia and mobility difficulties showed no evidence that neurological or vital sign monitoring was completed or documented after two separate unwitnessed falls. Interviews with staff confirmed that the required monitoring was not performed or recorded in the resident's records.