Failure to Follow Physician Orders and Timely Address Resident Care Needs
Penalty
Summary
The facility failed to follow physician orders and provide timely care for several residents. For one resident with acute respiratory failure, oxygen tubing was not changed weekly as ordered, with documentation showing the tubing was last changed six days prior to the observed date, despite orders for weekly changes. Another resident with multiple sclerosis and dysphagia had physician orders for staff assistance with feeding, but was observed feeding themselves with their fingers on multiple occasions without staff assistance, contrary to the orders. A third resident with chronic kidney disease had a physician-ordered fluid restriction, but records showed that both nursing and dietary staff failed to monitor and document fluid intake properly, resulting in the resident receiving more fluids than prescribed on multiple days. Additionally, a resident with Alzheimer's disease developed a body rash that was reported in June, but there was no evidence in the clinical record that the skin issue was addressed or assessed for a month, until a physician order for Nystatin cream was given in late July. Staff interviews confirmed these failures to follow physician orders and to address the resident's skin condition in a timely manner.