Failure to Follow Physician's Orders and Nursing Standards in Medication Administration
Penalty
Summary
The facility failed to adhere to a physician's order and professional standards of nursing practice during medication administration for two residents. In the first instance, an LPN was observed administering a Lidocaine 4% Patch to a resident's left knee without removing the previous patch as per the physician's order. The order specified that the patch should be removed at bedtime, but it was left on overnight due to a transcription error in the electronic health record, which scheduled the removal for the following morning instead of at night. This error was not caught by the pharmacy review or the 24-hour chart check, leading to the patch being left on longer than its effective period. In the second instance, another LPN administered blood pressure medications to a resident without rechecking a low diastolic blood pressure reading or notifying the physician. The resident's blood pressure was recorded as 108/40, which is below the recommended threshold, yet the LPN proceeded with administering amlodipine and Torsemide without confirming the accuracy of the reading or consulting the physician for guidance. The resident had a history of hypertension related to chronic kidney disease, and the care plan included monitoring for side effects and obtaining blood pressure readings under consistent conditions. The facility's policy on administering medications requires that medications be given safely and timely, as prescribed, and that any concerns about dosages or potential adverse consequences be discussed with the attending physician. In both cases, the nurses failed to follow these protocols, leading to the administration of medications without proper adherence to the physician's orders or verification of vital signs, which could potentially impact the residents' health.
Plan Of Correction
1. A. Resident #34 had [R] as a result of the deficient practice of nurses not following physician's order to remove [R] after the ordered duration (12-hour after placement). The [R] was removed and [R] assessed with no [R] noted and replaced with the ordered [R]. The order was clarified and updated to reflect correct removal time. B. Resident #49 had [R] as a result of the deficient practice of not retaking a [R] after initially getting a [R] and administering the medication without consulting the physician regarding the concern. Resident's doctor was notified and assessed Resident #49 and there were no new recommendations. 2. A. All residents with lidocaine patch orders have the potential to be affected by this deficient practice of nurses not following physician's order to remove lidocaine patch after the ordered duration (12-hour after placement). B. All residents with blood pressure medications could be affected by the deficient practice of not retaking a blood pressure after initially getting a low diastolic blood pressure and administering the medication without consulting the physician regarding the concern. 3. A. On 12/20/2024, a one-on-one in-service was completed by the Assistant Director of Nursing with LPN#1 who was responsible for resident #34's EXEC order 26,451 in question on transcription policy and removal of as ordered. Additionally, all nurses received education by the Assistant Director of Nurses on the policy and procedure for following physician orders for including removal and transcription. An audit was conducted for NJ Exec Order 26.4b1 orders to ensure proper order transcription. No further issues identified. B. On 12/20/2024, a one-on-one in-service was completed by the Assistant Director of Nursing with LPN#2 who was responsible for resident #49's medication administration on holding medication and seeking physician consultation when vital signs results show NJ Exec Order 26.4b1. Additionally, all nurses received education by the Assistant Director of Nurses on the policy to hold medication and seek physician consultation when vital signs results show NJ Exec Order 26.4b1. 4. The Director of Nurses, Assistant Director of Nurses, and Unit managers will audit new orders for lidocaine patches weekly for 4 weeks and monthly for 2 months to ensure all resident lidocaine orders are transcribed properly and followed. The Director of Nurses, Assistant Director of Nurses, and Unit Managers will audit med pass weekly for 4 weeks and monthly for two months to ensure any concerning vital sign results are communicated to the Physician for consultation prior to administration of medication. The results of these audits will be reported to the QAPI committee monthly for 3 months.