Failure to Provide and Document Care According to Physician Orders and Facility Policy
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards and physician orders for three residents. For one resident with diabetes and neuropathy, there were multiple instances where wound care and foot cradle checks were not documented as completed according to physician orders. The Treatment Administration Records showed several dates where required wound care and foot cradle checks were either not signed or not completed, and the Director of Nursing confirmed that this care and documentation should have occurred as ordered. Another resident with congestive heart failure and Parkinson's disease had physician orders for daily weights and required provider notification for specific weight gains. The clinical record revealed several occasions where the resident experienced weight gains that met the criteria for provider notification, but there was no evidence that the provider was notified as required by the orders. The Director of Nursing was unable to provide documentation or evidence that these notifications took place. A third resident, admitted with an infection related to a hip prosthesis and receiving IV antibiotics via a PICC line, had multiple missing entries in the Medication Administration Record and Treatment Administration Record for administration of antibiotics, saline flushes, and PICC line care. The records also showed incomplete documentation of PICC line dressing changes and measurements, with one instance of a measurement being recorded as zero, which was not accurate. The Director of Nursing confirmed the missing documentation and that staff should have completed and documented all required care and measurements as per policy and physician orders.