Failure to Follow Physician Orders and Document Care for Two Residents
Penalty
Summary
Licensed nursing staff failed to follow physician's orders and facility policies in the care of two residents, resulting in multiple deficiencies related to assessment, documentation, and implementation of care. For one resident with diagnoses including dementia, anxiety, and major depressive disorder, blood pressure and heart rate readings were not recorded or documented on the Medication Administration Record (MAR) for several days, despite orders to hold antihypertensive medications if certain parameters were not met. Both the licensed nurse and the Director of Nursing confirmed that vital signs should have been documented to ensure resident safety and continuity of care, as required by facility policy. Another resident, with end stage renal disease, congestive heart failure, and chronic respiratory failure, experienced several lapses in care. After returning from dialysis, the resident's arteriovenous (AV) fistula dressing was not removed within the required four-hour window, as observed and confirmed by both the resident and nursing staff. The failure to remove the dressing prevented proper assessment of the AV fistula site for complications such as infection or bleeding, contrary to facility policy and standard nursing practice. Additionally, this resident was administered oxygen at a rate higher than ordered, and oxygen saturation levels were not assessed on room air as specified in the physician's orders and care plan. Nursing staff acknowledged these errors and stated that oxygen should have been administered and monitored according to the orders. Facility policies and job descriptions reviewed during the investigation confirmed the expectations for accurate documentation, adherence to physician orders, and proper assessment procedures. Interviews with nursing staff and the Director of Nursing consistently indicated that these standards were not met in the cases reviewed, resulting in deficiencies in nursing competency and care delivery for the affected residents.