Failure to Implement Physician Orders for Lab Work and Daily Weights
Penalty
Summary
The facility failed to implement physician's orders for three residents, as evidenced by clinical record reviews and staff interviews. For one resident with peripheral vascular disease, a physician ordered a Complete Blood Count to be obtained on a specific date, but there was no documented evidence that the blood test was performed. The Director of Nursing confirmed that the blood work was not completed and that nursing staff did not communicate the order to the laboratory. Additionally, two other residents with chronic conditions, including chronic kidney disease, failure to thrive, congestive heart failure, liver cell cancer, and edema, had physician orders to be weighed daily. Review of their records showed multiple dates where there was no documentation that daily weights were obtained as ordered. The Director of Nursing confirmed the lack of documentation for these daily weights, indicating that the physician's orders were not followed for these residents.