Failure to Follow Physician Orders for Anticoagulation Monitoring and Oxygen Therapy
Penalty
Summary
The facility failed to follow provider orders and maintain professional standards of quality for two residents. For one resident on Warfarin therapy, physician orders required weekly Prothrombin Time and International Normalized Ratio (PT/INR) testing every Monday, with results to be communicated to the provider and documented in the nursing notes, including any new orders received. Record review showed that on multiple specified dates, there was no documentation that the INR was completed, results recorded, provider notified, or new orders obtained. The Director of Nursing confirmed that the required documentation was incomplete and that there was no record of INR results prior to a certain date. For another resident with a physician order for continuous oxygen to maintain oxygen saturation above 88%, a hospice nurse observed the resident being walked in the hallway without oxygen. Upon checking, the resident's oxygen saturation was found to be 82%. The hospice nurse immediately notified staff and ensured the resident was returned to her room and placed back on her oxygen concentrator. These findings indicate that staff did not consistently follow physician orders for both medication monitoring and oxygen therapy.