Failure to Follow Physician Orders and Document Care for Two Residents
Penalty
Summary
Staff failed to meet professional standards of practice for two residents by not following physician orders and not documenting required care. For one resident, who was admitted and later discharged from the facility, staff documented symptoms of burning during urination. The on-call physician ordered a urinalysis and urine culture due to these symptoms, but staff did not enter these orders into the electronic medical record (EMR), nor did they collect or document the collection of a urine sample. Interviews with staff and nursing leadership confirmed that the physician's order was present in a scanned document, but staff did not check scanned documents for orders and did not follow the expected process of entering and acting on such orders in the EMR. For another resident with diagnoses of hypertension and type 2 diabetes, staff failed to administer prescribed blood pressure medication (diltiazem) and insulin as ordered. Medication administration records showed multiple instances where the medication was not given, and staff used a code indicating 'other/see nurse note,' but there was no documentation that the physician was notified about the missed doses. Additionally, the resident experienced several episodes of elevated blood sugar levels above 400, but there was no documentation that the physician was notified as required by the order. Interviews with staff and nursing leadership confirmed that the provider was not notified about the unavailability of medication or the high blood sugar readings. The deficiencies were identified through record review and staff interviews, which revealed a lack of documentation, failure to follow up on physician orders, and failure to notify the provider as required. These actions and inactions resulted in the facility not meeting professional standards of quality for the care of these residents.