Failure to Follow Professional Standards in Physician Orders and Dietary Restrictions
Penalty
Summary
The facility failed to ensure that residents received care in accordance with professional standards of practice in two separate cases. In the first case, a resident with a diagnosis including fibromyalgia was readmitted and attended a urology consult, which recommended an increase in fluid intake. However, there was no evidence of a physician's order to encourage fluids upon the resident's return. The unit manager acknowledged that such an order should have been in place, and it was later revealed that an order to encourage extra fluids was entered by a nurse without consulting the resident's provider. The nurse practitioner confirmed she did not approve the order, and the nurse admitted to entering it without provider authorization. In the second case, a resident with dysphagia had a physician's order specifying that no paper products should be present on the meal tray. Despite this, the resident was observed with a tray ticket, tray mat, and napkin during a meal. Staff interviews confirmed awareness of the dietary restriction, but the items were still provided to the resident. The director of nursing stated that nursing staff are expected to review meal tickets and ensure compliance with such orders, but this was not done in this instance.