Failure to Follow Physician Orders and Provide Prescribed Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. In the first case, a resident with a history of stroke, right side weakness, and cognitive impairment experienced a fall and subsequently developed right arm pain and swelling. Although a Nurse Practitioner ordered x-rays of the right wrist and lower arm, the order was not properly entered into the electronic record, resulting in a delay. When the x-rays were eventually performed, they did not include all the ordered views, and the recommendations for further diagnostic imaging to rule out a fracture were not followed. Both the Nurse Practitioner and the Director of Nursing admitted to not reading the x-ray results in their entirety, and the necessary follow-up was not completed until much later. In the second case, a resident with Parkinson's disease and dementia suffered a fall resulting in a T3 compression fracture. The hospital provided an order for a TLSO brace to stabilize the spine, but the facility did not obtain or provide the brace upon the resident's return. Nursing staff and the DON were aware of the order but did not secure the brace, and there was confusion regarding responsibility for obtaining it. The resident went without the required spinal support for several days, during which time she continued to experience pain and was observed without the brace in place. The third case involved a resident with a gastrostomy tube and a history of urinary tract infections who was prescribed a 7-day course of Sulfamethoxazole-Trimethoprim for a UTI. The resident received only 10 out of 14 prescribed doses because the liquid suspension was not available in the facility and staff did not contact the pharmacy or utilize the backup pharmacy. There was no documentation explaining the missed doses, and neither the Nurse Practitioner nor the DON were notified that the full course of antibiotics was not administered.