Failure to Implement and Document Physician Orders and Interventions
Penalty
Summary
The facility failed to fully assess, implement, and document physician orders and interventions for multiple residents, resulting in unaddressed changes in condition and lack of appropriate care. For one resident with a history of constipation, there were repeated prolonged periods without bowel movements, with medical records showing gaps of up to 12 days. Despite standing and as-needed orders for various laxatives and enemas, documentation showed these interventions were not consistently administered or followed up on, and staff did not document the administration or effectiveness of these treatments. Additionally, after a dangerously low oxygen saturation was recorded, there was no documentation of frequent monitoring or administration of oxygen as ordered by the provider. Another resident with complex medical needs, including diabetes, did not have blood sugar checks performed as ordered, with staff only obtaining readings at bedtime instead of before meals and at bedtime. When blood pressure readings were out of range, the nurse withheld medication without a provider order or documented notification to the provider. For a resident receiving insulin, nurses continued to use the same injection site despite provider instructions to rotate sites due to bruising and tissue trauma, and there was no documentation of refusal to use alternative sites. Additionally, persistent complaints about a toenail were not escalated or monitored until the condition worsened and required medical intervention. The facility also failed to clarify and document orders related to intravenous therapy. One resident had an IV saline lock in place for a week after a one-time fluid administration, but there was no order or documentation for routine flushing and site maintenance as required by facility policy. Staff interviews confirmed that documentation and order transcription for IV care were incomplete, and the facility did not follow its own policy or provider orders for IV maintenance.