Failure to Follow Physician Orders and Ensure Monitoring for Diabetic and Medically Complex Residents
Penalty
Summary
The facility failed to follow physician orders and provide appropriate monitoring and documentation for residents with diabetes and other medical conditions. For one resident, blood glucose levels were not obtained for an extended period despite physician orders, and the order itself lacked parameters for when to notify the physician. Additionally, several residents had physician orders for blood glucose monitoring and insulin administration that either lacked clear notification parameters or were not followed when abnormal blood glucose readings occurred. In multiple cases, there was no documentation that the physician was notified of blood glucose results outside of the ordered parameters, and interventions for hypoglycemia were not documented. The review also found that for one resident prescribed Lithium, there were no physician orders for the required therapeutic lab monitoring, and the resident did not receive routine lab work to monitor Lithium levels. This omission was confirmed by the Director of Nursing. Furthermore, the facility failed to ensure timely follow-up physician appointments for another resident. The process for scheduling appointments and transportation was inconsistent, with staff interviews revealing a lack of communication and a standardized process, resulting in missed appointments and delays in rescheduling. These deficiencies were identified through a review of facility policies, clinical records, and staff interviews. The issues included failures in following physician orders, lack of documentation for critical interventions, absence of required monitoring, and inadequate processes for scheduling and communication regarding resident care. The findings were confirmed by interviews with the Director of Nursing and other staff members, who acknowledged the lapses in care and documentation.