Failure to Follow Physician Orders and Complete Required Assessments for Resident with Respiratory Issues
Penalty
Summary
The facility failed to follow physician orders and ensure appropriate follow-up assessments for a resident experiencing respiratory issues. Record reviews showed that the facility's policy required thorough evaluation and documentation when a resident had a change in condition, including the use of a Change in Condition Evaluation (CICE) form and communication with providers. However, for the resident in question, there was no evidence that a CICE was completed despite multiple episodes of wheezing and cough, and repeated administration of Ipratropium-Albuterol Inhalation Solution both as scheduled and as needed. Documentation revealed that the resident received several PRN and scheduled nebulizer treatments for wheezing and cough, with varying effectiveness noted by different staff members, including medication aides and nurses. There were instances where the effectiveness of the medication was not properly assessed or documented, and in some cases, medication aides, rather than licensed nurses, were monitoring the efficacy of the treatments. Communication with the physician was documented regarding the resident's worsening symptoms, but there was no evidence that follow-up assessments or changes in treatment were consistently implemented as directed. Interviews with staff, including an LPN and the Director of Nursing Services, confirmed that assessments were not completed as required and that medication aides should not have been responsible for monitoring the effectiveness of the nebulizer treatments. The DNS acknowledged that more could have been done by the nursing staff in response to the resident's change in condition, and that the facility did not adhere to its own policies or physician orders regarding assessment and follow-up care.