Failure to Follow Physician's Orders for Medication and Monitoring
Penalty
Summary
The facility failed to ensure that physician's orders were followed for two residents. Resident 40, who is cognitively intact and has diagnoses including high blood pressure, diabetes, and Parkinson's, did not receive medications as ordered on multiple dates in December 2024. The medications included Cetirizine, Synthroid, Miralax, Diltiazem, and Tylenol. An interview with Resident 40 confirmed that he had not been receiving his medications according to the physician's orders, and the Director of Nursing verified the lack of documentation for medication administration on the specified dates. Resident 53, who is cognitively impaired and requires assistance with daily care, had physician's orders for blood sugar monitoring and notification if levels were outside specified parameters. On two occasions, the resident's blood sugar levels were critically low, but there was no documented evidence that the physician was notified as required. The Director of Nursing confirmed that the physician was not informed of the low blood sugar readings, which was a failure to follow the physician's orders.
Plan Of Correction
1. The facility cannot retroactively correct Medication Administration Record (MAR). Physician updated on blood sugar readings and interventions of identified resident. 2. Charts of residents receiving routine blood sugar checks reviewed for notification parameters. 3. The Director Of Nursing/Designee will educate licensed staff on Physician orders and Administering Medications Policy and document education. 4. Audits of medication administration records to confirm signatures on 5 residents 5x per week x2 weeks, weekly x4. Findings will be monitored by the Executive Director and reported to Quality Assurance Performance Improvement Committee for additional oversight. Audits of 5 residents receiving blood sugar checks for documentation of notifications per physician orders 5x per week x2 weeks, Weekly x4. Findings will be monitored by the Executive Director and reported to Quality Assurance Performance Improvement Committee for additional oversight.