Failure to Obtain Physician Orders for Immediate Care Needs
Summary
The facility failed to ensure that two residents had physician's orders for their immediate care needs upon admission, specifically regarding oxygen therapy and colostomy care. One resident, a female with diagnoses including morbid obesity, heart failure, acute and chronic respiratory failure with hypoxia, and pneumonia, was admitted with a need for oxygen. Despite being on 4 liters of oxygen via nasal cannula, there was no physician order for continuous or as-needed oxygen supplementation, nor for related care such as changing the cannula, tubing, or humidifier, or for assessing the resident’s nares. Multiple staff interviews confirmed that an order should have been present and that the absence of such orders was a deviation from facility policy and standard practice. Another resident, a male with heart failure, chronic kidney disease, and acute respiratory failure, had a colostomy appliance but did not have an active physician order for colostomy care upon readmission. Although the care plan noted the presence of a colostomy and staff reported changing the pouch daily, there was no corresponding physician order in the treatment administration record after a certain date. Staff interviews revealed that the omission was not noticed during the readmission process, and the DON acknowledged that a physician order for colostomy care should have been present and care planned. Facility policy reviews confirmed that all treatments, including oxygen administration and colostomy care, require a physician's order to be recorded in the medical record. The lack of such orders for these two residents was identified through observation, record review, and staff interviews, and was not in accordance with the facility’s own procedures for ensuring safe and appropriate care.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with multiple chronic conditions and an indwelling Foley catheter did not have physician orders in place for the catheter at admission. Medical records, nursing notes, and the care plan lacked documentation of the catheter order, although CNA documentation confirmed care was provided and surveyors observed the catheter in use. The DON confirmed the absence of physician orders, and the facility lacked a related policy.
A resident with critical illness myopathy and moderate cognitive impairment was readmitted from the hospital without physician notification or medication and treatment orders in place. Staff, including an LPN, confirmed they lacked the necessary orders to provide proper care, and both the medical director and nurse practitioner were not informed of the readmission. The DON acknowledged the orders were not transcribed as required.
A resident with a surgical incision was admitted without proper orders for incision care, leading to a delay in treatment. The hospital recommended washing the incision twice daily, but the facility did not initiate this care until several days later. The ADON confirmed the oversight in obtaining necessary orders upon admission.
Lack of Physician Orders for Indwelling Foley Catheter
Penalty
Summary
The facility failed to ensure that physician orders were in place for a resident with an indwelling Foley catheter at the time of admission. The resident, who was admitted with multiple diagnoses including atrial fibrillation, congestive heart failure, liver cirrhosis, diabetes mellitus type 2, and chronic kidney disease with dialysis, was cognitively intact and required significant assistance with activities of daily living. Medical record review showed no physician orders for the Foley catheter, and there was no documentation in the nursing progress notes or plan of care regarding the catheter. Certified Nursing Assistant documentation confirmed care was provided for the catheter, and observations during the survey verified the presence of the indwelling Foley catheter. The Director of Nursing confirmed the absence of physician orders, and the facility did not have a policy related to physician orders for indwelling Foley catheters.
Failure to Notify Physician and Obtain Orders on Resident Readmission
Penalty
Summary
Licensed nursing staff failed to notify the physician of a resident's readmission and did not obtain medication or treatment orders to guide care for the resident upon return from the hospital. The resident, who had a diagnosis of critical illness myopathy and moderate cognitive impairment, was readmitted to the facility, but there was no evidence in the medical record that physician orders for medications or treatments were in place on the date of readmission. Staff interviews confirmed that the LPN working on the unit at the time did not have any orders to properly care for the resident and did not notify the provider of the resident's return. Further interviews revealed that both the medical director and nurse practitioner were not informed of the resident's readmission, and the director of nursing acknowledged that there was no reason for the failure to transcribe or enter the necessary orders. The administrator stated that it was expected for all orders to be entered and the provider notified immediately upon admission or readmission, but this did not occur in this instance.
Failure to Obtain Admission Orders for Surgical Incision Care
Penalty
Summary
The facility failed to ensure that admission orders were obtained for a resident with a surgical incision, which led to a deficiency in providing appropriate care and treatment. Resident #178, who was admitted with a surgical incision on the neck, did not have any orders in place to wash the incision as recommended by the hospital from which they were discharged. The hospital record indicated that the incision should be washed twice daily with soap and water, but this was not initiated until several days after the resident's admission. Upon observation, it was noted that the resident had clear tape covering the incision, and the resident reported that no treatments had been performed on it by the facility. The physician orders for the month did not include any instructions for incision care until an order was finally placed to wash the incision every shift. The Assistant Director of Nursing confirmed that there should have been an order in place upon admission to cleanse the surgical incision, which was not done, resulting in a lapse in care.
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