Failure to Meet Professional Standards in Assessment, Documentation, and Adherence to Physician Orders
Penalty
Summary
The facility failed to meet professional standards of quality for five residents due to multiple deficiencies in assessment, documentation, and adherence to physician orders. For one resident with a history of femur fracture, muscle weakness, and severe cognitive impairment, the licensed nurse did not accurately assess or document a change in skin condition, specifically a deep tissue injury, during the weekly assessment. Interviews with nursing staff confirmed that the required comprehensive skin assessment was not completed, and the injury was not documented as per facility policy and professional standards. Another deficiency involved residents with orders for oxygen therapy. One resident with diagnoses including congestive heart failure and acute respiratory failure did not receive oxygen therapy as ordered by the physician. Observations revealed the absence of an oxygen concentrator and nasal cannula, and staff confirmed that the resident was not receiving oxygen despite an active order. Similarly, two other residents received oxygen at incorrect flow rates, with one receiving a higher flow than ordered and another not receiving oxygen as prescribed. Staff interviews and record reviews confirmed that oxygen, considered a medication, was not administered in accordance with provider orders, contrary to facility policy and professional standards. Additionally, a resident with heart failure and Alzheimer's disease did not receive a prescribed medication (Trazodone hydrochloride) as ordered by hospice. The order was filed in the resident's chart but was not carried out, and the required notifications and documentation were not completed. Staff interviews confirmed that the process for verifying and implementing medication orders was not followed, resulting in the resident not receiving the intended medication. These deficiencies were corroborated by facility policies, job descriptions, and professional references reviewed during the survey.