Failure to Follow Physician Orders and Professional Standards of Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for multiple residents. One resident experienced two unwitnessed falls, but neurological assessments were either missing or incomplete, with several required evaluation intervals not documented. Another resident was observed sitting unsafely on the calf rests of a wheelchair, and two staff members repositioned the resident without a licensed nurse present to assess or guide the transfer, despite the care plan requiring total dependence with two staff and a mechanical lift for transfers. A third resident had physician orders to be encouraged and assisted to be up in a chair and in the dining room for meals, with specific instructions for wheelchair positioning. Observations revealed the resident's wheelchair was not set up as ordered, and documentation for assistance was missing on multiple occasions, as confirmed by the Director of Nursing. Additionally, a fourth resident had a physician order to hold insulin administration if blood glucose was less than 140, but insulin was administered multiple times when blood glucose readings were below this threshold, as shown in the medication administration records and confirmed by the Director of Nursing. These findings were based on record reviews, staff interviews, and direct observations, demonstrating that the facility did not consistently follow physician orders or ensure that care was provided according to professional standards for several residents. The deficiencies included failures in documentation, medication administration, post-fall assessment, and adherence to care plans for mobility and transfers.