Failure to Follow Physician Orders for Treatment and Device Management
Penalty
Summary
The facility failed to provide care and treatment as ordered by the physician for two residents. For one resident with diagnoses including high blood pressure, cancer, and a fracture, the physician ordered the resident to wear a sling at all times except for hygiene. However, observations on two separate occasions found the resident without the sling, and staff interviews confirmed that the sling was not in place as ordered. For another resident with diagnoses of atrial fibrillation, hypertension, and type 2 diabetes mellitus, the clinical record showed an order for insulin administration and noted the use of a continuous glucose monitoring device (libre). However, there was no active physician order for the use, care, or changing of the glucose monitoring device. The DON confirmed that no such order was present in the resident's record.