Failure to Provide Care and Documentation per Physician Orders and Standards
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for two residents. For one resident with end stage renal disease and dependent on renal dialysis, the hospital discharge summary and physician notes specified that Midodrine should be administered one hour prior to hemodialysis, typically at 5:00 AM. However, review of the Medication Administration Record showed that the medication was given at 5:30 AM and 5:25 AM on two occasions, rather than at the prescribed time. The DON confirmed that the medication was not administered at the correct time as ordered. For another resident with a history of dementia, failure to thrive, and multiple contractures, there was a lack of documentation and assessment following a complaint of right foot pain and observed swelling. Although the physician was notified and ordered the leg to be elevated, and later ordered an x-ray and doppler study, the medical record did not contain documentation of an assessment of the swelling, a specific pain assessment of the leg/ankle, or details of the conversation with the physician when the x-ray was ordered. The DON confirmed the absence of this documentation.