Failure to Obtain Physician Orders for Air Mattress Use and Hospital Transfers
Penalty
Summary
The facility failed to ensure that care was provided in accordance with professional standards of practice for three residents. For two residents with pressure ulcers or a history of falls, air mattresses were in use without physician orders specifying their use or the appropriate settings. Observations showed that the air mattresses were set at weights significantly higher than the residents' actual weights, and there was no documentation that nursing staff ensured the mattresses were properly adjusted or functioning as required by facility policy. The Director of Nursing confirmed that physician orders, including specific settings based on resident weight, were required but not present in the records. Additionally, a resident with dementia and a chronic skin condition was transferred to the hospital on three separate occasions without a physician's order for the transfer. Review of the medical record for each transfer date failed to show any order authorizing the transfer, and both a nurse and the DON acknowledged that such orders were required but missing. The facility's own policies and professional nursing standards require that physician orders be obtained and transcribed for both the use of specialized equipment such as air mattresses and for hospital transfers. The lack of such orders and documentation, as well as the failure to ensure equipment was set according to resident needs, constituted a failure to meet professional standards of quality care.