Failure to Follow Provider Orders and Professional Standards of Care
Penalty
Summary
The facility failed to ensure that services provided to three residents met professional standards of quality. For one resident with diabetes, stiff joints, muscle weakness, and heart failure, there was a provider order for protective boots to be placed on both heels every shift. However, the resident was observed in a wheelchair without the boots, and both the resident and staff confirmed the boots were only worn in bed. There was no documentation of the resident's refusal to wear the boots while up, and staff did not notify the provider or clarify the order as required. Another resident with dementia, COPD, hypotension, and depression had a provider order for midodrine to be held if systolic blood pressure exceeded 120. Despite this, the medication was administered on two occasions when the resident's blood pressure was above the specified parameter. Additionally, a third resident dependent on artificial feeding via a central line had no provider order in place for the care of the central line, including monitoring for infection or dressing changes. Staff confirmed that care for the central line was not provided as expected.