Failure to Follow Physician Orders and Provide Comprehensive Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for multiple residents. For one resident with diabetes, the facility did not notify the physician of abnormal capillary blood glucose (CBG) readings as required by the physician's order. Specifically, there were instances of both hyperglycemia and hypoglycemia where the clinical records did not show any physician notification or documented interventions, despite clear orders to do so. Interviews with nursing staff confirmed a lack of consistent understanding and adherence to the notification protocol for abnormal blood glucose levels. Two residents with skin condition concerns did not receive comprehensive skin assessments or appropriate care and treatment. One resident had wounds that were not assessed or had dressings changed for several days, resulting in the wounds increasing in size and worsening. Documentation was lacking regarding wound care between dressing changes, and staff interviews confirmed that the wounds were not addressed as needed. Another resident at risk for pressure ulcers did not have a Braden Scale assessment completed for several months, and when fluid-filled blisters were observed, there was no comprehensive skin assessment, care, or notification to appropriate parties documented in the clinical record. Additionally, the facility failed to follow physician orders for vital sign monitoring for a resident with a history of seizures and recent hospitalization. The hospital discharge instructions required vital signs to be taken every four hours, but the clinical record did not show that this was done. The resident's family reported concerns about the discontinuation of an anti-epileptic medication (Keppra) after a 30-day order expired, and the facility did not continue the medication or document a reason for not following the order. Interviews with facility leadership confirmed these failures to follow physician orders and provide the required care.