Failure to Implement Physician Orders and Timely Communication of Lab Results
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and residents' choices for two residents. For one resident with a history of a displaced femur fracture, diabetes, and moderate cognitive impairment, the facility did not implement the wound physician's recommendations for a skin tear in a timely manner. The wound care orders recommended by the consultant were not entered into the medical record or implemented for several days after being made, resulting in gaps in wound treatment. There was also no documentation that the attending physician was notified of the consultant's recommendations or that the physician declined to implement them. For another resident with severe sepsis, acute kidney failure, and an indwelling catheter, the facility failed to accurately transcribe and act on a physician's order to send the resident to the emergency room for evaluation. The order, which was faxed back to the facility, was misinterpreted by one nurse as an order to repeat labs in the morning, resulting in a delay of at least nine hours before the resident was transferred to the hospital. The original lab slip with the physician's written instructions was not included in the medical record, and there was confusion among nursing staff regarding the correct interpretation of the order. Additionally, the facility did not report abnormal urinalysis results to the physician in a timely manner for the same resident. The urinalysis, which showed significant bacterial growth, was reported to the facility but not communicated to the physician or documented as such in the medical record. The DON confirmed that there was no notification to the physician or documentation of the abnormal results, and the physician's office did not have a copy of the lab results or fax. These failures demonstrate lapses in communication, order transcription, and timely implementation of physician recommendations.