Failure to Follow Physician Orders and Professional Standards of Care
Penalty
Summary
Surveyor observations, record reviews, and staff interviews revealed that the facility failed to ensure residents received care in accordance with professional standards and physician orders. Multiple residents with air mattresses had their mattress settings incorrectly adjusted, not matching either the physician's order or the resident's current weight. For example, one resident weighing 119.6 lbs had their air mattress set to 300 lbs, while another resident weighing 141 lbs had their mattress set to 350 lbs. Staff interviewed were unaware of the correct settings, and the Director of Nursing Services confirmed that the settings should have matched the residents' weights or the specific physician orders. Additionally, a resident with a physician's order for continuous oxygen at 2 liters per minute was observed receiving oxygen at 4 liters per minute on several occasions. Staff acknowledged that the oxygen was not being administered as ordered, and the DNS stated that the physician's order should have been followed regarding the oxygen flow rate. Another deficiency was identified for a resident with an order for daily weights three times per week, with instructions to notify the physician if there was a weight gain greater than 3 lbs in a day or 5 lbs in a week. The resident experienced a weight gain of 5.4 lbs in one week, but there was no evidence that the physician was notified as required. Staff interviews confirmed that the weight gain was not reported to the physician, and the nurse practitioner and DNS both indicated that notification should have occurred per the order.