Failure to Follow Physician Orders and Treatment Protocols
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 an intravenous (IV) catheter, there was no physician order for IV dressing changes, and the dressing was observed to be loosened and half peeled away with an outdated change date. Staff confirmed that the dressing had not been changed as required by facility policy, which mandates dressing changes at least every seven days or when soiled, damp, or loose. Another resident with bilateral below-the-knee amputations had physician orders for daily wound care, including cleansing and application of antibiotic ointment dressings to both stumps. However, observation revealed that one stump had a dressing dated two days prior, and the other stump had no dressing in place. Staff confirmed that the treatments were not completed as ordered. Additionally, two residents did not have timely follow-up physician appointments ordered or scheduled as required, despite documented physician orders for follow-up with specialists such as urology, neurology, and endocrinology. Staff interviews confirmed that these appointments had not been made. Furthermore, a resident with an order for a daily lidocaine patch did not have the patch labeled with the date and time of application during a medication pass, as required by facility policy. The LPN administering the medication confirmed the omission. These findings demonstrate failures to follow physician orders, maintain proper documentation, and adhere to facility policies for treatment and care.