Failure to Verify Death per Policy and Delay in Transcribing Physician Orders
Penalty
Summary
The deficiency involved the facility’s failure to follow its own process for verification of death for a resident with DNR status. Resident C, who had diagnoses including nontraumatic chronic subdural hemorrhage, heart failure, and dementia, was found by a CNA to have expired. The nurse documented that upon entering the room, the resident was unresponsive, pale, cold, and not breathing, and that the resident had a DNR order. The time of death was recorded as 10:22 p.m., and the physician and family were notified. However, the clinical record did not contain documentation that a second nurse assessed and verified the resident’s death, despite staff indicating that two nurses were required to verify the death of a resident with DNR status. A second deficiency involved the failure to timely transcribe and implement physician orders for another resident. Resident D, who had diagnoses including macular degeneration and glaucoma, was seen by an optometrist, who prescribed artificial tears three times daily, Preservision AREDS 2 capsules twice daily, discontinuation of Latanoprost eye drops, and initiation of Brimonidine 0.1%–dorzolamide 2% eye drops twice daily. The clinical record lacked documentation of these prescribed orders on the date they were written and showed they were not documented until several days later. Staff reported that orders should be transcribed on the same day they are written, and the facility’s policy stated that all physician orders received pertaining to the resident will be implemented and followed as the orders are received.
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