Failure to Provide Needed Care and Services per Physician Orders
Penalty
Summary
The facility failed to provide necessary care and services to three residents whose changes in health status were not adequately assessed, and physician's orders and treatments were not administered as required. For one resident with renal insufficiency, diabetes, and depression who received dialysis, there was a lack of evidence that physician orders for medication adjustments and dietary changes were implemented. Orders to increase phosphorus supplementation and to change from a fluid-restricted to a fluid-pushing diet were not reflected in the resident's medical record. Additionally, orders to monitor blood pressure twice daily following hypotensive episodes were not carried out, and a basic metabolic panel lab draw was not completed as ordered. Communication lapses between the dialysis unit and facility staff, as well as missed medication administration and failure to document attempted lab draws, contributed to the resident being sent to the emergency department due to low blood pressure and suspected electrolyte imbalances. Another resident with anemia, hypertension, diabetes, and hyponatremia had orders for lab work and compression stockings that were not fulfilled. The lab draws were not completed prior to the provider's next visit, and the resident was found to be pale and edematous, requiring transfer to the emergency department where acute on chronic congestive heart failure was diagnosed. There was confusion among staff regarding the status of the compression stockings, with the nursing assistant unaware of the order and the clinical coordinator stating the resident refused them, but the resident later expressed willingness to try a larger size. The facility lacked a system to track lab completion, and staff absences contributed to the missed lab draws. A third resident with heart failure, seizure disorder, and traumatic brain injury did not receive a prescribed anticonvulsant medication due to an allergy being incorrectly recorded in the facility's records, despite the resident having taken the medication prior to admission without issue. The medication was not administered for nearly two weeks after admission, and there was a lack of follow-through in clarifying the allergy status and ensuring the medication was provided as ordered. The facility's policies required timely and accurate transcription of medication orders and prompt resolution of medication errors, but these were not followed, resulting in the resident not receiving necessary treatment.