Failure to Accurately Transcribe and Implement Physician Orders for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for two residents, specifically in the transcription of admitting diagnoses and physician orders. For one resident with a complex medical history including sickle cell disease with crisis, alcoholic cirrhosis, multiple fractures, anemia, and end stage renal disease, the face sheet and order summary did not accurately reflect all admitting diagnoses. The paper chart listed only sickle cell pain crisis as the admitting diagnosis, omitting other significant conditions. Additionally, there were no physician orders for monitoring hemoglobin levels or routine lab work, despite the resident's high risk for complications due to her medical conditions. Interviews with nursing staff revealed a lack of awareness regarding orders for lab monitoring, and the baseline care plan did not address the resident's sickle cell disease with crisis. For another resident admitted with extensive third-degree burns and other diagnoses, the facility failed to transcribe and implement wound care orders as provided by an outpatient surgical specialist. The specialist's instructions included daily bathing and gentle washing of the lower extremities before moisturizing, but the facility's orders only specified the application of Aquaphor ointment to the thighs twice daily, omitting the washing step. Interviews with the resident and staff confirmed that the skin was not washed prior to ointment application, and staff were unaware of the full wound care instructions. The care plan referenced treatment as ordered but did not specify the complete wound care regimen. Facility policy required that new or changed physician orders be entered promptly and completely, including all directions and administration details. However, interviews with the ADON, Regional Compliance Nurse, and ADM revealed that orders from outside providers were not always reviewed or transcribed accurately into the residents' charts. This led to discrepancies between the care provided and the prescribed treatment, as well as incomplete documentation of residents' medical conditions and care needs.