Failure to Provide Timely Treatment, Medication, and Adherence to Physician Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals in three separate incidents involving three residents. In the first incident, a resident reported experiencing crusting and itching in the eyes to an LPN, who verbally informed the attending physician but did not document the concern in the electronic health record or follow up when the physician did not immediately address the issue. The physician was unaware of the complaint during the initial visit and only addressed the concern days later after being informed. The lack of documentation and follow-up resulted in a delay in treatment for the resident's eye symptoms. In the second incident, a resident with a diagnosis of type 2 diabetes and a prescription for Zenpep (pancrelipase) to aid digestion was admitted to the facility but did not receive the medication as ordered. The medication was not available upon admission, and the resident was unable to eat during the entire stay. Although the pharmacy notified the facility via fax that the medication was unavailable and required a dose change, there was no evidence that staff followed up with the physician or nurse practitioner. The resident left the facility the next day, having not received the necessary medication or food for 19 hours. In the third incident, a resident with a history of hemodialysis and recent AV graft placement had clear physician orders and signage indicating that blood pressure measurements should only be taken on the lower extremities, not the arms. Despite these orders, staff documented 27 instances of blood pressure measurements taken on the resident's arms after the orders were in place. Interviews revealed that staff were either unaware of the orders or did not follow them, and documentation errors were also noted. These failures demonstrate a lack of adherence to physician orders and proper communication among staff regarding resident care requirements.