Failure to Follow Physician Orders for Two-Person Care and Cardiology Consult
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and professional standards of practice for two residents. One resident, readmitted in July 2025 with chronic inflammatory demyelinating polyneuropathy and lymphedema, had a physician’s order dated 7/10/2025 requiring two staff members at all times for resident care. On 8/27/2025 during the 7:00 AM to 3:00 PM shift, the resident was taken to the shower room by a facility NA and a hospice NA. The facility NA assisted with transferring the resident into the shower chair via a Hoyer lift along with the hospice NA, but the hospice NA then showered the resident alone. During the shower, the hospice NA observed active bleeding from an unidentified source, and when nursing staff arrived, a pool of blood was noted in the bathroom. A skin assessment revealed an open area with a split to the skin on the top of the right great toe, and progress notes documented a traumatic wound to the distal tip of the right great toe with copious blood drainage and active bleeding. The NA assigned to the resident stated she was not aware that the resident required two staff members for care at all times, and record review did not show evidence that two staff members were present for care during the shower as ordered. The second deficiency concerns a failure to carry out a physician’s order for a cardiology consult for another resident. This resident was readmitted in September 2025 with diagnoses including myocardial infarction and cerebral infarction and had existing physician’s orders for aspirin 81 mg daily and Plavix 75 mg daily. A progress note dated 10/30/2025 documented that the resident was on dual antiplatelet therapy with aspirin and Plavix, and the pharmacy recommended discontinuation of Plavix. This recommendation was reported to the physician, who issued a new order to obtain a cardiology consult prior to discontinuing the medication. A physician’s order dated 10/31/2025 directed staff to obtain a cardiology consult for possible discontinuation of Plavix. Record review failed to show evidence that a cardiology consult had been scheduled, and the Scheduler reported being unaware that the resident needed a cardiology appointment and had not reached out to schedule it.
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