Failure to Ensure Physician-Ordered Appointments and Wound Care Orders
Penalty
Summary
The facility failed to ensure that a resident with a history of congestive heart failure, ischemic cardiomyopathy, and other cardiac conditions attended a physician-ordered follow-up cardiology appointment after returning from a hospital stay for shortness of breath and CHF exacerbation. Although the LPN entered the order for the follow-up appointment into the medical record, there was no documentation that the appointment was scheduled or attended. Both the LPN and the DON were unable to verify whether the appointment was arranged or completed, indicating a lapse in following through with physician orders for post-hospitalization care. Additionally, the facility did not ensure that wound care treatment orders were written and included in the care plan for a resident with a traumatic brain injury and multiple fractures who was receiving wound care for an open area on the left shin. The wound care was being performed as recommended by a visiting wound care service, but there was no corresponding order in the medical record, nor was the treatment addressed in the resident's comprehensive care plan. The wound nurse confirmed that the order for wound care had not been entered into the system, despite performing the treatment as directed by the wound care service.