F0684

E

Failure to Follow Physician Orders, Complete Neuro Checks, and Accurately Document Post-Operative and Medication Care

Cambridge, Maryland Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures by facility staff to provide treatment and care in accordance with physician orders and professional standards of practice for several residents. For one resident, the medical record review showed that a prescribed Triamcinolone Acetonide mouth/throat paste ordered to be applied after meals and at bedtime for seven days was not started until several days after the initial order. A subsequent order for the same medication to be given twice daily for seven days was not administered for multiple AM and PM doses on specified dates. During the same period, the resident did not receive ordered PM doses of several other medications and supplements, including eye drops, fish oil, a health shake, Lactobacillus, Naprosyn, and Vitamin C. The VP of Clinical Services confirmed these missed medication administrations.

Another deficiency involved a resident with a history of cerebral infarction with hemiplegia and hemiparesis who experienced multiple unwitnessed falls. The facility’s fall investigation documentation and neuro check assessment forms showed that ordered or expected neuro checks after these falls were either incomplete or entirely absent. For one fall, only two neuro checks were documented despite a form indicating a detailed schedule of frequent checks over 72 hours. For two other falls, there was no documentation of any neuro assessments. For a later fall, only nine neuro checks were documented, and the pattern did not match the expected frequency and duration, with missing four-hour checks and no continuation of neuro checks through 72 hours. The facility’s head injury policy stated that neuro checks should be performed as indicated or as specified by the physician but did not define specific timing or frequency.

The same resident also had documented low Vitamin D levels, with NP progress notes indicating a plan to start Vitamin D supplementation at specified daily doses. However, there was no corresponding physician order entered into the electronic system, and review of the Medication Administration Records for several months showed no Vitamin D being administered. The NP later confirmed that the order had never been entered into the system while the NP was still learning the system. Additionally, an NP note documented an order for orthostatic blood pressure measurements in response to repeated falls and concern for hypotension related to a medication, but review of the MAR, TAR, vital signs, and nursing notes revealed no documentation that orthostatic blood pressures were ever obtained. The Director of Clinical Operations confirmed that no orthostatic blood pressures were performed.

A further deficiency involved another resident who sustained a right hip fracture after a fall and underwent open reduction internal fixation of the hip in the hospital. The hospital discharge summary instructed that the resident should have a follow-up appointment with the surgeon as soon as possible within one week, but the resident was not seen until several weeks later. Wound assessments documented the presence of surgical staples at one point and a resolved surgical site at a later date, but there was no documentation in the medical record of when the staples were removed. NP notes over a period of time continued to document that the staples were clean, dry, and intact, even though the staples had been removed sometime between two documented assessment dates. There were no physician orders for staple removal and no assessment documented after the staples were removed, and leadership staff acknowledged that the timing of staple removal could not be determined from the record.