Failure to Follow Physician Orders for Urology Referral and PEG Site Care
Penalty
Summary
The facility failed to follow physician's orders regarding a urology referral and did not obtain an order for PEG site care for two residents. For one resident, after being readmitted with multiple diagnoses including hydronephrosis, renal calculous obstruction, and sepsis, a physician's order was given for a urology referral following a stent placement. Despite documentation of the need for a referral and communication with the physician's office, the appointment was never made. Additionally, the resident's care plan was not updated to reflect their post-hospitalization status. Interviews with nursing staff and the Director of Nursing confirmed that the urology appointment was not scheduled as ordered. For another resident with a PEG tube, there was no physician's order for PEG site care documented in the medical record or on the Treatment Administration Record for several months. Nursing staff confirmed the absence of an order and indicated that care should have been performed daily and documented, but there was no formal process in place to ensure this without an order. Observation of the resident's PEG site showed it was clean and dry, but the lack of an order and documentation represented a failure to follow required procedures for PEG site care.