Failure to Follow and Obtain Physician Orders for Treatments, Medications, and Adaptive Devices
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards by not following or obtaining physician orders for multiple residents. One resident with a right wrist fracture and respiratory illness was observed sitting in a wheelchair with a right wrist brace and receiving O2 at 2 L/min via nasal cannula. Record review showed there were no physician orders for either the oxygen therapy or the wrist brace. The DON confirmed that the resident had a wrist brace and was receiving oxygen without corresponding orders in the electronic medical record and stated that nurses should have addressed this and obtained provider orders, but this did not occur. Another resident with type 2 DM, morbid obesity, and long-term use of insulin and injectable non-insulin antidiabetic drugs had multiple sequential orders for weekly Mounjaro injections. Review of the MAR showed missed Mounjaro doses on three specific dates. The resident reported that the facility was not consistently administering the weekly injection and that some weeks the medication was not available and the dose was skipped. The ADON confirmed the missed doses, explaining that the medication was not available on two of the dates due to pharmacy/insurance pre-authorization issues, and that on another date the medication arrived several days late and the resident refused it because it was too close to the next scheduled dose; the ADON stated nurses should have requested the medication from the pharmacy as soon as they knew it was not available, but this did not happen. A resident with hemiplegia, vascular dementia with behavioral disturbance, aphasia, and dysphagia had a dietary order for a scoop plate and a sippy cup for hot beverages. During a meal observation, this resident was served hot coffee in a regular cup despite the meal slip indicating a sippy cup for hot beverages. The admissions coordinator confirmed that the hot coffee was served in a regular cup and acknowledged that, per the dietary order, all hot beverages should have been served in a sippy cup, which did not occur. Additional deficiencies involved adaptive eating devices and the lack of corresponding physician orders. One resident with multiple sclerosis, type 2 DM, generalized muscle weakness, and a right rotator cuff tear had a care plan specifying built-up utensils for all meals, but record review did not show a physician order for built-up utensils. Another resident with Alzheimer’s disease, vascular dementia, psychophysiologic insomnia, and hearing loss had a care plan for rehab eating devices, including a scoop plate during meals, but there was no physician order for a scoop plate. A further resident with a left hand contracture, orthostatic hypotension, restless legs syndrome, and a neurostimulator had a care plan for built-up utensils for all meals, yet no physician order for built-up utensils was found. In interviews, the OT stated that he evaluates residents for built-up utensils, notifies the dietitian and dietary so the devices are placed on meal tickets, and that if a resident needs built-up utensils for a long period of time, a physician order is needed, which was not present in these cases.
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