Failure to Follow Physician Orders and Document Care for Multiple Residents
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for several residents, resulting in deficiencies related to medication administration, wound care, and response to acute medical needs. For one resident with cerebrovascular disease and scoliosis, a physician ordered a urine analysis with culture and sensitivity (UA/C&S) after multiple falls, but the test was never completed or documented, and no laboratory results were found. The Director of Nursing (DON) confirmed the order was not fulfilled and could not provide additional information. Another resident with multiple wound care orders for a diabetic toe wound had several days where treatments were not documented as completed on the Treatment Administration Record (TAR). The DON acknowledged that some treatments were performed during wound rounds but were not properly documented, and could not explain other missed entries. Additionally, this resident received more than the recommended daily dose of acetaminophen due to overlapping orders, which were not discontinued as new orders were placed, as confirmed by the DON. A resident with diabetes and end-stage renal disease missed scheduled insulin doses on multiple days when away for hemodialysis, despite the care plan indicating diabetes medication should be administered as ordered. Another resident with hemophilia and a history of hematuria experienced blood in the urine, but staff did not notify the hemophilia treatment center as ordered, and the prescribed medication for bleeding was not administered until nearly 24 hours after the initial observation. The DON confirmed the lack of documentation and delayed response. Finally, a resident with a skin tear did not have wound treatments documented on two occasions, with the DON unable to provide an explanation. These findings demonstrate failures in following physician orders, documenting care, and responding to residents' clinical needs.