Failure to Follow Physician Orders and Complete Required Monitoring After Falls
Penalty
Summary
The facility failed to provide necessary care and services for two residents by not following physician recommendations and not completing required monitoring after incidents. For one resident, a psychiatric evaluation recommended starting Depakote for poor impulse control, but there was no documentation that this recommendation was communicated to or obtained from the physician, and the medication was not initiated. Additionally, after this resident experienced a fall, the medical record did not show evidence that neurological checks were performed as documented in the progress note, despite facility policy and staff statements indicating that such checks should be completed for 72 hours post-fall. The same resident was later prescribed Seroquel for mood disturbance, with informed consent obtained from the responsible party. However, there was no documented evidence that orthostatic hypotension monitoring was implemented, even though this is a known side effect of Seroquel and was acknowledged as necessary by the DON. The lack of monitoring for orthostatic hypotension was verified during interviews and record reviews with facility staff. For a second resident, after an unwitnessed fall, the progress note and IDT recommendation indicated that neurological checks should be performed for 72 hours. However, the medical record did not contain documentation that these checks were initiated. Both RN 1 and the DON confirmed that neurological checks were not completed as required, despite the resident's lack of capacity to make decisions and the facility's policy to monitor for changes in neurological status after a fall.