Failure to Follow Physician Orders and Document Weights, Vitals, and Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure services were provided in accordance with professional standards of quality for multiple residents in the areas of nutrition, medication monitoring, and respiratory care. For a resident with hypertension, heart failure, and dementia, the comprehensive care plan and a physician’s order required weekly weights and notification of a provider for a weight gain of five pounds or more. Review of the electronic medical record, including the Medication and Treatment Administration Records, progress notes, and Weights and Vitals Summary, showed that weights were not obtained for 2 of 10 ordered instances and that there was no documented evidence of recorded weights for 4 of 10 instances. The DON acknowledged that weights were expected weekly per orders and that the nurse should document them in the Weights and Vitals Summary, but could not verify whether the weights had been obtained or documented as ordered. Another deficiency occurred in the monitoring and documentation of vital signs for a resident with hypertension, dementia, and a history of stroke who was receiving antihypertensive medication. The care plan directed staff to monitor vital signs as ordered, and a physician’s order required daily blood pressure and heart rate checks with provider notification for specific abnormal values. Record review showed that for 5 of 10 instances there was no documented blood pressure, and for 4 of 10 instances there was no documented heart rate with numerical values, even though the treatments were signed off as completed in the electronic Treatment Administration Record. Staff interviews confirmed that nurses were responsible for checking vital signs and that results should be documented in the Weights and Vitals Summary or treatment record; however, the LPN manager and DON both stated they could not verify that the blood pressure and heart rate had actually been obtained because the numerical results were not documented. A further deficiency was identified in the administration of oxygen therapy for a resident with congestive heart failure, COPD, and supplemental oxygen dependence. The care plan and Kardex indicated that oxygen was to be administered per medical orders and that staff should use oxygen as ordered and notify the provider if oxygen was not in use. During observation, the resident was in bed with a nasal cannula connected to an oxygen concentrator running at three liters per minute, but review of current medical orders revealed no physician’s order for continuous oxygen at that time. An order for supplemental oxygen via nasal cannula at three liters per minute was only obtained the following day. Nursing staff and the nurse practitioner stated that a provider order was required for oxygen, that oxygen is considered a medication, and that a medical order specifying the liter flow is needed because of the risk of over-oxygenation.
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