Failure to Adhere to Professional Standards and Physician Orders
Penalty
Summary
The facility failed to provide services that met professional standards of practice for seven residents, as evidenced by multiple instances of not following physician orders and established facility policies. For one resident with hypertension, a nurse administered Lisinopril without checking or documenting the required blood pressure parameters, despite a physician order to hold the medication if systolic blood pressure was below 100. The nurse acknowledged missing the order's parameters and not verifying the blood pressure prior to administration. Both the physician and the Director of Nursing confirmed that the expectation was for nurses to follow orders as written. Another resident with significant cognitive and physical impairment was ordered to wear a left palm guard during the day to prevent contractures. Despite this, the device was not observed in use during multiple surveyor visits, and staff interviews revealed a lack of awareness about the order. Documentation in the care plan and CNA Kardex failed to reflect the current order, and the device could not be located in the resident's room. Nursing staff had been signing off on the treatment administration record as if the device was in use, but could not confirm its application or whereabouts. Additional deficiencies included failure to complete medication reconciliation and implement all hospital discharge medications for a resident readmitted from the hospital, as well as not following orders for assistive devices and air mattress settings. Other residents did not receive pain medication or assistive devices as ordered, and documentation was incomplete or inaccurate regarding the application and removal of topical pain patches. In one case, a resident prescribed an antipsychotic did not have the required Abnormal Involuntary Movement Scale (AIMS) assessment completed after medication initiation. These findings were based on direct observation, interviews with staff and residents, and review of medical records and facility policies.