Failure to Follow Physician Orders for Wound, Medication Access, and Bowel Management
Penalty
Summary
The facility failed to follow professional standards of practice in providing care according to physician orders and resident care plans for two residents. One resident with a left below-knee amputation and right above-knee amputation had a physician order dated 12/26/25 for a wound vac to the left below-knee residual limb with continuous suction at 125 mmHg every shift. Observation on 1/5/26 showed the wound vac attached instead to the right above-knee residual limb. The DON reported she had transcribed the order incorrectly and later revised the order, but the revision still documented the wound vac to the right BKA, which did not match the resident’s actual physical assessment. The same resident also had an order for Biotene mouthwash for dry mouth and a care plan indicating self-administration of medication after the nurse prepares it, with Biotene observed at the bedside. The DON later stated the medical record should have included an order allowing the Biotene to be kept at the bedside, but no such order was present. Another resident with COPD and diabetes had multiple physician orders for a bowel management regimen, including Milk of Magnesia, prune juice, Dulcolax suppositories, and Fleet enemas to be administered as needed on specified days without a bowel movement. The medical record documented a bowel movement on 12/28/25 and then not again until 1/4/26, indicating more than 168 hours without a documented bowel movement. During this period, there was no documentation that the ordered bowel management medications were administered. The DON stated that this resident should have received the ordered medications for bowel management but had not.
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