Failure to Obtain and Transcribe Physician Orders for Immediate Care on Admission
Penalty
Summary
The facility failed to ensure the timely receipt and transcription of physician orders for immediate care upon admission for two residents. For one resident with Alzheimer's disease and visual loss, there was a 12-day delay in obtaining and administering prescribed ophthalmic medications, including Timolol-Dorzolamide-Latanoprost and Latanoprost, which were documented as necessary for the resident's glaucoma and visual loss. Despite the medications being listed in the pre-admission physician note and the family inquiring about them, the orders were not transcribed or administered until nearly two weeks after admission. Progress notes indicate that staff were aware of the need for these medications and communicated with the resident's ophthalmologist, but the actual orders and administration were delayed. Another resident with acute and chronic respiratory failure, pneumonia, and COPD was admitted without a physician order for supplemental oxygen, despite having a care plan intervention for oxygen and being observed with low oxygen saturation levels. The resident was seen in the dining room without oxygen, and staff later provided an oxygen tank holder and tubing after observing low oxygen saturation readings. However, review of the medical record confirmed that no physician order for oxygen was present from admission through the time of the survey, even though oxygen was administered when low saturation was detected. Interviews with facility leadership confirmed that the required physician orders for both medications and oxygen were not present or transcribed at the time of admission for these residents. The facility's own policy requires documentation and verification of physician orders for care and treatment, but this process was not followed, resulting in a lack of necessary medications and treatments for the affected residents.