Failure to Follow Physician Orders for Pressure Ulcer Care and Antibiotic Administration
Penalty
Summary
A resident with diagnoses including type 2 diabetes mellitus and gout, and with a history of a right heel pressure ulcer and osteomyelitis, did not receive care and treatment as ordered by the physician. The resident's care plan required turning and repositioning every 2 hours and administration of antibiotics for a right heel infection. However, documentation was missing for several doses of prescribed antibiotics (Clindamycin and Cephalexin) and wound treatments on specific dates. The medication administration record (MAR) and treatment administration record (TAR) lacked evidence that these orders were carried out as scheduled. Additionally, the resident was not consistently included on the CNA assignment form for turning and repositioning, despite the care plan directive. Interviews with staff revealed inconsistencies in understanding and implementing the resident's care plan. A CNA stated the resident was not listed as needing to be turned and repositioned every 2 hours, while the DON confirmed that such interventions were required and should have been documented. The DON also indicated that staff should have attempted to wake the resident for treatments, and that MAR and TAR entries should not have been left blank. The facility did not have a specific policy related to following physician's orders, though the Assistant Administrator stated it was their practice to do so.