Failure to Complete Physician-Ordered Treatments, Medications, and Lab Testing
Penalty
Summary
The facility failed to provide treatments, administer medications, and obtain laboratory testing as ordered by the physician for a resident with multiple complex medical conditions, including acute osteomyelitis, sepsis due to MRSA, diabetes, peripheral vascular disease, congestive heart failure, atrial fibrillation, dementia, and an open surgical wound. The resident was at risk for skin breakdown and had a physician order for daily wound care, but the treatment administration record showed no evidence that the wound care was completed on several specified days. The Director of Nursing confirmed there was no documentation of the required treatments on those dates, despite facility policy requiring immediate documentation after treatment. Additionally, the resident experienced critically low potassium levels as revealed by laboratory results. Although the physician provided orders for immediate administration of potassium and anti-nausea medication, there was no evidence in the medical record that these medications were administered or that the orders were entered as required. Interviews with nursing staff confirmed a lack of recall or documentation regarding the administration of these medications, and the DON verified the absence of evidence for the ordered interventions. Facility policy required that verbal orders be transcribed and executed or safely handed off, but this process was not followed in this case.