Failure to Follow Physician Order for 1:1 Monitoring
Penalty
Summary
The facility failed to follow physician orders for one resident who had a documented need for 1:1 monitoring. The resident, who had diagnoses including polyarthritis and severe cognitive impairment due to unspecified dementia with behavioral disturbances, was involved in a resident-to-resident altercation. Following this incident, physician orders were issued for 1:1 monitoring and additional 30-minute checks every shift for a specified period. However, staff interviews and record reviews revealed that the facility did not assign staff to provide 1:1 monitoring on at least two days, and there was no documentation that the resident's behaviors were evaluated or that the physician was contacted to clarify the ongoing need for 1:1 monitoring. Further review indicated that the care plan and physician orders were clear about the need for 1:1 monitoring, but the facility did not have a policy stating that such orders should automatically end after a certain period. The Director of Nursing and Director of Staff Development both acknowledged that staff should have reassessed the resident and communicated with the physician regarding the continuation of the order. The facility's policy required licensed nurses to ensure physician orders were clear and complete, including the duration when appropriate, but this was not followed in this case.