Failure to Follow Physician Orders and Address Care Refusals per Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards of practice for a resident with complex medical conditions, including a history of blood clots, dementia, vision problems, and dependence on staff for all ADLs. The admission MDS and ADL care plan documented that the resident had significant cognitive loss, exhibited care-rejecting behaviors, and required two-person assistance for bed mobility and transfers with a mechanical lift. A hospital discharge summary documented two pressure injuries (right heel and right buttocks) and included specific physician orders for wound care, turning every two hours in bed, getting the resident out of bed three times daily, nutritional supplements (Ensure TID and Juven BID), and transfer with a sit-to-stand lift to a tilt-in-space wheelchair. Record review showed that key physician orders were not timely implemented or were entered incorrectly. The physician orders for the resident to be out of bed three times daily were not entered into the physician order system from admission through early February, and there was no documentation that staff clarified these orders despite repeated notation by the provider in progress notes. POC documentation for transfers out of bed showed no entries indicating the resident was ever transferred out of bed, and bed mobility documentation contained multiple shifts with no documentation or entries that no assistance was given or the activity did not occur. The facility delayed implementation of the Juven order until six days after admission and the Ensure order until twenty days after admission, and the MAR showed several days when Juven was not administered because it was on order and unavailable. The TAR showed the wound treatment frequencies for the right heel and right buttocks were reversed from the hospital discharge orders, with the heel ordered daily instead of every three days and the buttocks ordered every three days instead of daily. The facility also failed to adequately assess, document, and address the resident’s refusals of care and to notify the provider. The behavior care plan contained no specific behaviors or interventions despite documentation that the resident refused seventeen meals, one bath, weekly weights on five occasions, and medications at times. Progress notes documented episodes where the resident refused to swallow medications, refused repositioning at times, refused a bladder scan, and refused or spit out an antibiotic and Ensure, but the notes did not consistently indicate what actions staff took in response or whether the provider or resident representative was notified. The DON later stated that the resident did not have the cognitive ability to understand the risks and benefits of refusing turning, and acknowledged that the provider should have been notified of refusals and that refusals and related behaviors should have been reflected in the behavior care plan to direct staff in managing them.
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