Failure to Follow and Clarify Physician Orders and Notify Providers
Penalty
Summary
Nursing staff failed to follow and/or clarify physician orders and did not notify providers as required for three residents. For one resident, daily weights were ordered, but significant weight variances exceeding three pounds in 24 hours were not reported to the provider on multiple occasions, and there was no documentation of such notifications. Another resident had an order for metoprolol with specific parameters for holding the medication and notifying the physician; however, staff held the medication multiple times when the resident's vital signs were within the ordered parameters, and did not notify the physician as required. Additionally, this resident experienced a weight loss of 5.8 pounds in 24 hours, but there was no documentation that the physician was notified as ordered. For a third resident, there was an order to flush a PICC line with normal saline and, if non-valved, with heparin. The order was transcribed without specifying whether the PICC was valved or non-valved, making it unclear if the appropriate flushes, including heparin, were administered. The DON confirmed that the documentation did not clarify this and that staff did not seek clarification of the order.