Failure to Follow Physician Orders for Labs, Infection Control, Medications, and Fluid Restriction
Penalty
Summary
The deficiency involves multiple failures to follow physician orders and professional standards of quality for several residents. One resident with dementia had increased agitation and confusion, prompting the provider to order blood work and a urine specimen for culture and analysis. Progress notes documented that the resident refused to provide a urine sample on one date and that staff were unable to obtain the specimen on another date, but the record contained no evidence that the urine specimen was ever obtained or that the provider was notified of the inability to obtain it. The resident’s physician later stated he did not recall being informed and would have expected notification, and the DNS also stated she would have expected the specimen to be obtained as ordered or the provider to be notified with documentation. Another resident with neuromuscular bladder dysfunction and a suprapubic catheter had a care plan and physician order requiring Enhanced Barrier Precautions (EBP) every shift, including use of gown and gloves for high-contact care such as personal hygiene. EBP signage on the resident’s door instructed staff to wear a gown and gloves for activities like dressing, bathing, hygiene, and changing briefs. A surveyor observed a nursing assistant in the resident’s room adjusting bed linens while wearing only one glove and no gown, and the assistant reported she had just completed personal care without a gown despite acknowledging the EBP signage, stating she had been told a gown was not required. The Infection Preventionist stated she would have expected staff to wear a gown when assisting with the resident’s personal care. Additional deficiencies involved medication management and fluid restriction orders. One resident with stroke and seizures had physician orders for gabapentin and two eye medications, but the MAR showed frequent refusals of all three medications over many days, with no documentation that a provider was notified of these ongoing refusals. A medication technician stated the resident often refused medications and that she simply marked them as refused, without indicating that she notified a nurse or provider, while the DNS stated she would have expected such refusals to be communicated and documented. Another resident with dementia had an order for hydroxyzine pamoate three times daily, but the MAR showed multiple missed doses on several days without evidence that the provider was notified or that the doses were given, and the DNS could not provide evidence the medication was administered as ordered. A further resident admitted with hypo-osmolality and hyponatremia had dietary orders for thin liquids with no free water due to a fluid restriction and a regular diet with a fluid restriction, but the record did not specify the amount of fluid allowed. A progress note documented that the MD was contacted because information about the limitation was unclear and that it was due to low sodium, yet there was no evidence the order was clarified, and both a medication technician and the physician later confirmed that the specifics of the restriction were not defined in the order.
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