Failure to Complete Physician-Ordered Labs and Neurological Assessments
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs in two separate cases. For one resident with severe cognitive impairment and multiple chronic conditions, the facility did not complete physician-ordered laboratory tests, including a urinalysis and several blood draws, prior to a scheduled nephrology appointment. As a result, the laboratory work was not available for the appointment, leading to the appointment being rescheduled. Family interviews confirmed that missed or delayed laboratory tests had resulted in rescheduled or missed appointments for this resident. The Director of Nursing verified that the laboratory tests were not completed as ordered. In another case, a resident with severe cognitive impairment, multiple diagnoses, and on anticoagulant therapy experienced a fall resulting in a head injury. The care plan required neurological assessments at specific intervals following the fall. While initial 15-minute checks were completed, subsequent 30-minute and hourly checks were missed or incomplete. Documentation showed that the nurse responsible was passing medications on another hall during the missed assessments. Additionally, at one assessment time, only vital signs were taken, and the resident could not be fully assessed as she was sleeping. The Director of Nursing confirmed that the neurological checks were not completed as required and that family and medical staff notifications about the fall and injury were delayed. Interviews with staff and review of records confirmed that the required care and monitoring were not provided according to physician orders and facility protocols. The deficiencies affected two of three residents reviewed for quality of care and treatment, as verified by the Director of Nursing and staff interviews.