Failure to Follow Physician Orders for Labs, Weights, and Respiratory Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards and person-centered care plans for two residents. One resident, re-admitted with a sacral pressure wound infection and a history of pressure ulcers, had physician orders for weekly laboratory tests, including ESR, while on IV antibiotics. The medical record showed that after an initial high ESR result, a subsequent test was not completed due to a laboratory issue, and there was no documentation of follow-up for the missing result. The weekly ESR order was later discontinued by the provider without explanation or documentation regarding the missing test or the rationale for discontinuation. Another resident, admitted with diagnoses including liver failure, heart failure, and pulmonary hypertension, had physician orders for daily weights and CPAP therapy at night. The resident reported not receiving weekly weights or CPAP since admission, despite documentation in the MAR indicating CPAP was provided. Observations confirmed the absence of a CPAP device in the resident's room, and the last recorded weight was over a month prior. Staff interviews revealed a lack of awareness of the resident's heart failure diagnosis and uncertainty regarding the process for obtaining a CPAP device, despite existing orders.