Failure to Follow Physician Orders for Weights and Lab Tests
Penalty
Summary
The facility failed to follow physician orders for two residents as identified during a recertification and complaint survey. For one resident with documented weight loss, medical records showed that weekly weights were ordered to be obtained every Sunday for two separate four-week periods. However, weights were either missing or not obtained on the specified days as ordered. Specifically, two out of four required weights were not obtained during the first period, and the remaining weights were not taken on the correct day. In the second period, one required weight was missing, and the others were not obtained on the ordered day. These findings were confirmed by the Nursing Home Administrator during a review of the records. For another resident, a medication regimen review conducted by a pharmacist resulted in a recommendation to order a serum magnesium level, which was agreed to and signed by the provider. An order for the magnesium level was subsequently placed, but there was no evidence in the medical record that the lab was completed or that results were obtained. The Director of Nursing confirmed that no lab results were available for the ordered test. These deficiencies were identified through review of medical records and staff interviews.