Failure to Follow Physician Orders and Professional Standards of Practice
Penalty
Summary
The facility failed to follow professional standards of practice for seven residents by not adhering to physician orders and not ensuring required services were provided as ordered. For five residents, staff did not obtain or document ordered bloodwork, including therapeutic medication level monitoring and other diagnostic tests. There was also no documentation that physicians were notified when bloodwork was not obtained or was uncollected, despite repeated orders for labs such as Depakote levels, ammonia levels, CBCs, and other critical tests. Interviews with staff and review of records revealed ongoing issues with lab orders not being scheduled or completed, and a lack of follow-up or communication with providers regarding missed labs. One resident with hypertension and diabetes did not have blood pressure or pulse checks documented prior to administration of antihypertensive medication, despite specific parameters in the physician's order. Additionally, blood sugar checks (Accu Checks) were not consistently performed or documented as ordered, and staff were unclear about the requirements for monitoring and documentation. Interviews with the resident and staff confirmed that blood pressure and blood sugar checks were not being performed as required, and documentation practices were inconsistent or incomplete. Another resident with orders for a nutritional supplement (Magic Cup) did not receive the supplement as ordered, and staff documented administration even when the supplement was not available. Observations and interviews with dietary and nursing staff revealed confusion about responsibilities for providing and documenting supplements, and the supplement had not been available for some time. The resident reported not receiving the supplement, and staff confirmed that documentation was based on assumption rather than direct observation or confirmation of administration.