Failure to Implement Physician Orders and Required Monitoring Across Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician-ordered medications, treatments, assessments, monitoring, and interventions were implemented as ordered for multiple residents during a specific day shift. Surveyors found that required pain assessments ordered every shift were not completed for several residents with conditions such as alcohol abuse, depression, anxiety, chronic pain, and other complex medical issues. For example, residents with orders for 0–10 pain scale assessments each shift did not have these assessments documented on the Treatment Administration Record (TAR) for the identified day shift. The DON confirmed that these ordered pain assessments were not completed as required. The report also details failures to carry out specific clinical and safety-related orders for residents with significant medical and functional needs. One resident with chronic respiratory failure and severe cognitive impairment had an order for head-of-bed (HOB) elevation each shift, a diet communication for a mechanical soft diet with thin liquids, behavior monitoring with documentation of interventions, and use of t‑shirts instead of nightgowns; these orders were not implemented or documented on the day shift. Another resident with anoxic brain damage, a PEG tube, tracheostomy, and multiple orders related to tube feeding and respiratory status did not receive ordered PEG tube flushes, PEG placement checks, gastric residual checks, HOB elevation, SpO2 monitoring, or the ordered pain assessment during the same shift. Additional residents with COPD and other respiratory diagnoses had orders for HOB elevation that were not carried out, and residents with diabetes did not receive ordered blood glucose monitoring. Further, the facility did not implement infection control and safety interventions as ordered. Residents with orders for enhanced barrier precautions (EBP) every shift did not have these precautions implemented during the day shift, despite orders requiring staff to use gloves and gowns during high-contact care. One resident with COPD and other conditions did not have EBP or HOB elevation implemented, and monitoring associated with oxygen therapy, PT/OT range-of-motion exercises, and use of an Acapella device for secretion clearance was not documented. Other residents with behavioral health or cognitive conditions had physician orders for behavior monitoring and documentation of interventions every shift, as well as increased supervision after meals for safe transfers and placement of a sign instructing the resident to call for assistance before self-transferring; these interventions were not completed or documented. The DON consistently confirmed during interview that the various ordered assessments, monitoring, precautions, and safety measures were not implemented on the identified day shift, resulting in multiple residents not receiving ordered care and services.
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