Failure to Follow Physician Orders and Care Plans for Enteral Feeding, Podiatry, Hip Abductor, and Oxygen
Penalty
Summary
The deficiency involves multiple failures to follow physician orders and care plans for several residents. One resident with a gastrostomy tube had an order for Glucerna 1.2 at 85 mL/hr for 20 hours, with the feeding to remain on until a specified time and serving as the resident’s only source of nutrition and hydration. During observation, the resident was in bed with the enteral feeding pump turned off, despite the order indicating it should have been running. The feeding bottle showed only about 250 mL infused when approximately 510 mL should have been administered based on the start time and ordered rate. The wound care nurse confirmed the pump was off without any reason documented and that the feeding should have been on according to the electronic health record and care plan. Another deficiency concerns a resident with diabetes mellitus, muscle weakness, and Parkinson’s disease whose care plan included monitoring for skin issues and need for assistance with ADLs. The resident reported ongoing severe foot pain, describing toenails digging into the skin and throbbing in the feet, and stated having repeatedly asked staff for three months to have a doctor examine the feet. On examination, an LPN found markedly overgrown, thickened, discolored toenails with sharp, irregular edges, and multiple areas of hard, dry, scaly skin on the plantar surfaces of both feet. There was no prior podiatry order in the EMR, and staff acknowledged that no podiatry consult had been placed until the surveyor raised the concern. The most recent MDS did not document the existing hard, dry, patchy areas on the feet, and the care plan did not reflect a need for skilled foot care or interventions related to the poor foot condition, despite facility policies on ADLs, grooming, and resident rights. Additional deficiencies include failure to follow physician orders and care plans for a resident with a right hip fracture and hip replacement, and a resident with an order for continuous oxygen. One resident had an active order and care plan requiring use of a hip abductor device while in bed, with specific instructions for placement from hip to ankle level and proper strap fit, but the report indicates the facility did not ensure the device was applied as ordered. Another resident with diagnoses including COPD, encephalopathy, obstructive sleep apnea, and hyperlipidemia had an active physician order for oxygen at 3 L via nasal cannula to be used continuously, and the facility failed to follow this order. These combined actions and inactions affected four residents reviewed for quality of care.
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