Failure to Follow Physician Orders for Wound Care, IV Antibiotics, Weights, and I&O Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered treatments and medications for two residents with serious infections and other comorbidities. One resident with MSSA infection, endocarditis, and altered mental status was admitted with a thoracic/chest wound that, per email and attached orders, required a wound vac at a specified pressure setting with continuous suction and dressing changes three times weekly and as needed. The hospital discharge summary indicated the resident was to continue cefazolin with weekly labs and that the wound vac was in place at discharge, with no order to discontinue it. However, the facility’s medical record contained no evidence that a wound vac order was entered, that the wound vac was to be discontinued, or that the resident refused it. Instead, a subsequent order directed daily Dakins-based wound care to the left chest incision, and the treatment record showed that this wound care was not provided on multiple specified dates, with no nursing notes explaining the missed treatments. The same resident had an order for IV cefazolin 2 g every eight hours for infection, with a defined end date. The MAR showed the 6:00 a.m. dose on one date was given, but subsequent scheduled doses over the next day and a half were not administered because the medication was not available from the pharmacy. A nursing note documented that the pharmacy reported the medications had left the pharmacy and were still en route, yet there was no documentation that the resident or representative was notified, nor that the physician was notified or provided new orders to hold the medication or use backup stock. In interview, the DON confirmed the IV medications were not given as ordered due to non-arrival from the pharmacy, that providers were not notified, and that no new orders were obtained. A second resident with diagnoses including UTI, cord compression, extradural and subdural abscess, CKD, unstageable pressure ulcer, and diabetes had multiple physician orders that were not consistently followed or documented. An order for daily weights with parameters to notify the physician for specified weight gains lacked documented weights on numerous listed days in December. An order for meropenem 1 g IV every eight hours for a thoracic epidural abscess until a specified end date showed no documented administration on three specific dates. Additionally, an order to monitor intake and output every shift for fluid restriction and CHF had multiple shifts with no intake and output documentation on both day and night shifts. In interviews, the DON verified the missing daily weights, missed meropenem doses, and absent intake and output documentation on the identified dates and shifts.
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