Failure to Follow Physician Orders and Professional Standards in Resident Care
Penalty
Summary
Nursing staff failed to follow physician orders and facility policies in the care of two residents. For one resident with a history of cerebrovascular disease, major depressive disorder, and vascular dementia, nurses did not monitor and document blood pressure in the lying position as ordered for orthostatic hypotension assessment on three consecutive Tuesdays. The Assistant Director of Nursing confirmed that the required blood pressure checks were not performed or documented, and the Director of Nursing acknowledged that this failure prevented identification and management of orthostatic hypotension. Additionally, after the same resident experienced a fall, neurochecks were not completed or documented at seven required intervals within a 72-hour period post-fall. Interviews with nursing staff revealed that neurochecks were missed due to distractions and failure to follow post-fall protocols. The Director of Nursing confirmed that the facility's policy required neurological assessments after falls, and that these were not performed as expected, which could have delayed identification of changes in the resident's condition. For another resident with diabetes mellitus, cerebral vascular accident, and major depressive disorder, nurses failed to rotate insulin injection sites as ordered and per facility policy on multiple occasions. Both the Licensed Vocational Nurse and the Director of Nursing confirmed that insulin injections were repeatedly administered at the same site by different nurses, contrary to physician orders and manufacturer guidelines. This practice was acknowledged as inconsistent with professional standards and facility policy, which require rotation of injection sites to prevent complications.