Failure to Monitor Anticoagulant Therapy, Follow Hospice Orders, and Ensure Diabetes Education at Discharge
Penalty
Summary
The facility failed to provide appropriate care and services for three residents by not ensuring proper monitoring and adherence to physician orders. For one resident on anticoagulant therapy, there was no documented monitoring for signs and symptoms of bleeding in the medication administration records for several months, despite care plans and physician orders requiring such monitoring. Staff interviews confirmed that the monitoring was not scheduled or documented, and the coding on the medication record was incorrect, which could have led to the order being missed. Another resident receiving hospice care had conflicting physician orders between the hospice provider and the facility, with no interdisciplinary team meetings conducted as ordered by the hospice physician. The facility staff did not clarify or follow the hospice physician's orders, leading to confusion about which orders to follow and potentially affecting the resident's plan of care. The facility's policy required coordination with hospice representatives to ensure appropriate care, but this was not done. A third resident, who had diabetes and was being discharged home, did not receive a documented evaluation of their or their family member's knowledge regarding diabetes management, including blood sugar checks and insulin administration. The discharge instructions did not confirm whether the resident or family member understood how to manage diabetes care at home, and there was a lack of timely confirmation with the home health agency regarding post-discharge nursing support. The facility's policy required teaching and discharge instructions to be provided and understood prior to discharge, but this was not ensured.