Failure to Follow Physician Orders and Post-Injury Monitoring Protocols
Penalty
Summary
The facility failed to follow physician orders and established protocols for the care and treatment of residents using respiratory equipment and for monitoring after a head injury. For one resident, staff did not change or date nebulizer tubing and masks as ordered, nor did they store the CPAP mask in a clean, dry area or use a respiratory setup bag when not in use. Multiple observations showed the nebulizer tubing was undated and the CPAP mask was improperly stored, with staff interviews confirming these lapses. Additionally, another resident with significant cognitive and physical impairments, who was on anticoagulant therapy, developed a large bruise on the forehead. Staff did not measure the bruise, communicate with the practitioner or responsible party, or initiate neurological checks as required by facility policy after a head injury. The etiology of the bruise was not investigated in a timely manner, and documentation of the injury and related assessments was delayed.