Failure to Obtain Physician Orders for Immediate Care Needs
Penalty
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.