Failure to Follow and Clarify Physician Orders and Document Care Provided
Penalty
Summary
The facility failed to ensure that physician's orders were followed and properly documented for several residents. For three residents at risk of or with existing pressure ulcers, air mattress settings were not maintained as ordered by the physician. In one case, the air mattress was set at 300 pounds instead of the ordered 160-180 pounds, and staff acknowledged the mattress could not be set to the prescribed range and that the order should have been clarified. Another resident's air mattress was set at 200 pounds instead of the ordered 100-110 pounds, despite staff documenting that the mattress was monitored every shift. Additionally, a resident received blood pressure and diuretic medications outside of the ordered parameters, with staff confirming that medications were not held as directed when blood pressure readings were below the specified threshold. The facility also failed to ensure that nurses only signed for treatments after they were provided. In one instance, a nurse did not sign the Medication Administration Record (MAR) immediately after administering morning medications to a resident with complex medical needs, as required. Furthermore, there was a lack of clarification of physician's orders for another resident receiving artificial nutrition via feeding tube; the order specified the rate of administration but did not indicate the type of nutrition to be used, and staff did not seek clarification from the provider. Additionally, the facility did not ensure that physician's orders were in place prior to providing certain types of care. One resident was observed receiving supplemental oxygen without a corresponding physician's order, and staff confirmed that an order should have been obtained but was not. Another resident was found using a low air loss mattress for pressure relief without a specific physician's order for that device, and staff acknowledged the absence of an appropriate order. These failures were identified through observation, interview, and record review, and placed residents at risk for unmet needs and ineffective or delayed treatments.