A resident with a history of cerebral infarction, dementia, and glaucoma did not receive ordered Dorzolamide HCI-Timolol Maleate eye drops after an LPN accidentally discontinued the medication in the system without a physician’s order. The MAR showed the drops were not administered because no active order was available, and nursing documentation later confirmed the facility had discontinued the eye drops without provider authorization. In interviews, the administrator and DON acknowledged that the medication had been stopped in error and that there was no physician order to discontinue it.
Surveyors found that two residents were receiving clinical interventions without required physician orders. One resident with serious neurological diagnoses was observed using O2 via nasal cannula with an O2 concentrator in the room, but record review showed no corresponding physician order, despite facility policy requiring an order specifying flow rate, method, usage, and indication. Another resident was observed with a Foley catheter collection bag hanging from the bed, yet no physician order for the catheter was present in the record, contrary to the facility’s catheter policy requiring medical necessity and valid justification. An LPN, the ADON, and the DON all confirmed the absence of appropriate orders for these treatments.
Two residents experienced deficiencies in care when staff did not follow physician orders for oxygen therapy and STAT diagnostics. One resident with COPD and acute respiratory failure had orders for continuous O2 at 5.5 LPM via nasal cannula, yet was repeatedly observed with the portable O2 device turned off or set below the ordered flow, without a nasal cannula attached, and with an empty portable tank, resulting in low O2 saturations on room air. Staff acknowledged the resident required assistance with O2 therapy, and a CNA reported removing the nasal cannula and not replacing it. Another resident recovering from a right femur fracture developed severe left knee pain with swelling and decreased range of motion; an after-hours provider ordered STAT CBC, CMP, CRP, and a STAT left knee X-ray, but these were not completed because the orders were not documented correctly, causing a delay. The DON confirmed that O2 was not provided as ordered and that STAT labs and imaging were not obtained immediately due to documentation errors.
A resident receiving hospice care did not have physician orders for hospice services in the medical record. Review of the chart showed signed hospice documents and confirmation from the Social Services Director that the resident had been admitted to a hospice agency, but no corresponding physician order was found. The DON acknowledged that physician orders for hospice should have been present and confirmed they were missing from the resident’s record.
Colostomy Care Not Ordered or Documented: A resident with a colostomy did not have colostomy care orders entered at admission, and staff did not document colostomy care before the orders were finally entered. Nursing notes showed the colostomy bag was changed, but the ADON and DON confirmed there was no documentation of care before the order date and they could not determine whether care was provided during the gap.
A resident with chronic systolic CHF and COPD was repeatedly provided O2 via nasal cannula without any corresponding physician order documented in the EHR. Nursing notes showed multiple instances of O2 administration, and surveyors observed an O2 concentrator with nasal cannula and a portable O2 tank in the room. The resident reported using O2 when experiencing shortness of breath. The UM and Administrator both acknowledged that residents requiring supplemental O2 should have valid physician orders and confirmed that no such order existed for this resident, meaning O2 was administered outside of professional standards of care.
A resident with an order for Losartan for hypertension had specific parameters requiring the medication to be held and the MD notified if the systolic BP was below 110, diastolic BP below 60, or pulse below 60. During a medication pass, an LPN recorded a BP of 103/61 and administered the Losartan despite the order to hold it under those conditions. In an interview, the DON confirmed that staff are expected to follow physician orders as written and that this did not meet expectations for medication administration.
Surveyors found that the facility failed to meet professional standards by not completing required AIMS assessments for two residents on antipsychotic medications, not providing ordered feeding assistance to a resident care planned for substantial help with eating, and allowing an LPN to administer heparin using an insulin syringe instead of appropriate injection equipment. The DON and ADON confirmed that AIMS assessments should have been done for residents on antipsychotics, that staff should have been present to assist the resident during meals per the care plan and physician order, and that insulin syringes are intended only for insulin and should not have been used for heparin.
Two residents experienced medication-related deficiencies when staff failed to follow professional standards for medication availability, administration, and monitoring. One resident with an order for Jardiance to control blood sugar had the drug marked as given on the MAR on several days even though it was not available and not administered, while an LPN checked the resident’s blood sugars without a physician’s order and did not document the results. Another resident with a history of cerebral infarction and hemiplegia had multiple ordered warfarin doses missed, and the DON later confirmed the missed doses and stated she had not been informed that the high-risk medication had not been given as ordered.
Facility staff failed to follow and document multiple physician and hospice orders, resulting in care that did not meet professional standards. A resident on hemodialysis had a fluid restriction order from dialysis that was never entered into the medical record, and staff reported the resident was not on fluid restriction. A resident with uncontrolled DM had orders to monitor blood glucose and a care plan directing monitoring for signs and symptoms of hypo- and hyperglycemia, yet staff did not document routine blood sugar checks, refusals, or symptom monitoring over several months after insulin orders were partially discontinued. Another resident with painful mycotic toenails had an ordered follow-up foot care appointment that was never scheduled, leaving toenails overgrown and thick. A resident with a sacrococcygeal pressure wound had updated hospice wound care orders for daily treatment that were not entered into the medical record, the prior less-frequent order remained active, and wound care was not documented on at least one ordered day.
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