Failure to Follow Physician Orders and Coordinate Care for Multiple Residents
Penalty
Summary
The facility failed to ensure physician orders were clarified and followed for multiple residents, resulting in deficiencies in care. For one resident with a history of major depressive disorder, alcohol abuse, and chronic viral hepatitis, daily weights were ordered to monitor for fluid overload following pulmonary congestion and administration of Lasix. However, nursing staff did not clarify with the physician when to report significant weight changes, and the physician was not notified of notable weight gains, despite expectations for communication of a two-pound overnight or five-pound weekly increase. Staff interviews revealed a lack of awareness regarding the purpose of daily weights, and the Director of Nursing acknowledged the failure to clarify notification parameters. Another resident with cerebral infarction, diabetes, hemiplegia, and COPD developed new open skin lesions acquired in-house. The care plan included interventions for skin integrity, but documentation showed incomplete weekly skin assessments and no referral to the wound care team after the development of new wounds. Progress notes indicated worsening of the lesions, and the Assistant Director of Nursing confirmed inconsistencies in assessment completion and the lack of timely referral, contrary to facility policy requiring thorough wound documentation and care. A third resident with congestive heart failure, hypertension, and diabetes had physician orders for blood sugar checks before meals and at bedtime, with instructions to notify the physician if levels were outside specified parameters. Review of records revealed frequent missing blood sugar checks and numerous instances of elevated blood sugars without physician notification. The DON verified the monitoring and notification failures, and the nurse practitioner confirmed that additional interventions could have been ordered if notified. Additionally, a resident on hospice care did not have documentation of coordinated care planning or communication with the hospice agency, as required by facility policy, and staff could not locate hospice information in the designated binders.