Failure to Follow Physician Orders and Document Care According to Standards
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and residents' choices for three residents. For one resident with congestive heart failure and hypertension, staff did not document reassessment or provider notification after multiple instances of severely elevated blood pressure and increased edema, despite care plan directives to monitor and report such changes. The Director of Nursing (DON) confirmed that while verbal notifications may have occurred, there was no documentation in the medical record to support this. Another resident with muscle weakness and cognitive communication deficit experienced a distended abdomen with absent bowel sounds, a condition associated with serious complications. Nursing notes showed that the resident had not had a bowel movement in over 72 hours and continued to have abdominal distention. The provider was not notified of the absent bowel sounds until the following day, despite the DON acknowledging that absent bowel sounds are considered an emergency. A third resident, admitted for care following sepsis and multiple liver abscesses, had three abdominal drain tubes. There were conflicting physician orders regarding the amount of sterile saline to flush the drains, and new orders were not implemented on the treatment administration record (TAR) until the day after they were received. Additionally, the record did not document the amount of fluid drained from the collection bags on several dates, and nurses did not follow the physician order to record output as directed.