Failure to Review and Implement Physician Orders
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for one resident reviewed for physician orders. A resident with diagnoses including respiratory failure, depression, and weakness, who was dependent on staff for activities of daily living and cognitively intact, reported persistent pain that was not controlled by their current dose of hydrocodone. The physician documented in the progress notes a plan to increase the hydrocodone dosage and to order a renal function panel, with a possible increase in lisinopril if the panel was stable. However, the nursing staff did not review the physician progress notes after the physician's rounds, and the Resident Care Manager was unaware of the new medication orders. The Director of Nursing stated that the expectation was for Resident Care Managers to review the physician notes the same day as rounds, but this was not done. As a result, the physician's orders for medication changes were not implemented in a timely manner. The Medical Director was not aware that the lisinopril dose had been increased and stated that they would have expected communication from the nursing staff regarding this change. The lack of review and communication regarding the physician's documented plan led to a delay in addressing the resident's pain management and medication adjustments, which did not meet the facility's policy or professional standards of practice.