Failure to Follow Physician Orders for Post-Fall Assessments, Therapy, Weights, and Vital Signs
Penalty
Summary
Facility staff failed to follow physician orders and established protocols for multiple residents, resulting in deficiencies related to post-fall assessments, neurological checks, therapy orders, and vital sign monitoring. In several cases, after residents experienced falls—some unwitnessed and some resulting in injuries such as fractures—staff did not complete neurological assessments as ordered or per facility protocol. For example, one resident who fell and sustained abrasions did not receive timely or complete neurological checks, with significant gaps between assessments. Another resident who suffered a hip fracture after an unwitnessed fall had no documented nursing assessment or complete neurological evaluations, and vital signs recorded were outdated. Staff interviews revealed uncertainty about the frequency and policy for neuro checks, and the facility was unable to provide a clear policy during the survey. In addition to post-fall care deficiencies, the facility did not carry out therapy and weight monitoring orders as prescribed by physicians. One resident with a right proximal humerus fracture had orders from an orthopedic surgeon for range of motion therapy, but therapy staff were unaware of these orders and did not initiate the prescribed therapy until the surveyor's intervention. The same resident also had orders for daily and weekly weights, but the documentation showed that weights were not obtained as ordered, with missed days and incorrect timing. Another resident with orders for daily weights had only one weight recorded, and the unit manager confirmed the orders were not followed. Further, the facility failed to follow a physician's order to obtain full vital signs every morning for a resident, instead only monitoring blood pressure. Staff interviews confirmed that the order was not being followed as written, and the medication administration record reflected only blood pressure checks. The facility was unable to provide a policy for following physician orders when requested. These findings were confirmed through observation, record review, and staff interviews, and were acknowledged by facility leadership during the survey.