Failure to Follow Physician Orders for Medication, Catheter Care, and Vital Signs
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. For one resident with a history of traumatic secondary hemorrhage, seroma, and high cholesterol, Heparin doses were missed on 18 occasions due to the medication being unavailable. Documentation showed that staff did not notify the physician of the missed anticoagulant doses, as required by facility policy. The resident reported that the facility frequently ran out of Heparin, and the Director of Nursing (DON) confirmed the missed doses and lack of physician notification. Another resident, admitted with urinary retention and nephritis, was re-admitted after a hospital stay for a urinary tract infection. Hospital discharge instructions required discontinuation of an indwelling catheter and a trial of voiding with bladder scans and specific documentation. These orders were not followed, as the catheter was not discontinued, bladder scans were not performed, and there was no documentation of the required procedures. The DON and a registered nurse acknowledged that the discharge orders were overlooked, and it was revealed that the facility's bladder scan machine had been broken for months. A third resident had physician orders for regular vital sign monitoring, which were not completed as required. The electronic medical record did not prompt staff to take vital signs due to incorrect order entry, and the last recorded vitals were from the resident's admission several months prior. Staff confirmed that vital signs were not taken as ordered, and the DON stated that vital signs should be completed per physician orders and on admission for baseline.