Failure to Follow Physician's Orders for Medication and Monitoring
Penalty
Summary
The facility failed to implement physician's orders for two residents, leading to deficiencies in care. Resident 16, diagnosed with hypotension, had a physician's order for midodrine to be administered three times a day on specific days, with the condition that it should not be given if the resident's systolic blood pressure (SBP) exceeded 130 mmHg. However, the medication was administered seven times in November and four times in December when the resident's SBP was above the specified limit. Resident 56, with diagnoses including cerebral infarction, chronic kidney disease, and chronic osteomyelitis, had a physician's order to be weighed weekly for four weeks and then monthly. The facility failed to document the resident's weight on three specified dates in November. The Director of Nursing confirmed these lapses in care during an interview.
Plan Of Correction
1. Resident 16's is receiving Midodrine according to physician orders. Resident 56 is being weighed according to physician orders. 2. An initial audit will be completed by the Director of Nursing/Designee on current residents with Midodrine orders to ensure they are receiving medication according to physician orders. An initial audit will be completed by the Director of Nursing/Designee on current residents to ensure weights completed according to facility policy or physician orders. 3. Licensed Nursing staff will be re-educated on following physician's orders with special attention to orders with parameters and weights. 4. The DON/designee will complete weekly random audits to ensure weights are completed according to facility policy or physician orders. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.