Failure to Clarify Physician Orders for Three Residents
Penalty
Summary
The facility failed to clarify a questionable physician's order for three residents, leading to deficiencies in care. For one resident, there was an order to flush a feeding tube with water before and after administering medications, despite the resident no longer receiving medications through the tube. Interviews with the resident and staff confirmed that the feeding tube was not in use for medication administration, yet there was no documented evidence that the physician was contacted to clarify the order. Another resident, who was cognitively intact and had diabetes, had a physician's order to receive insulin at specific times. However, the resident did not receive the insulin on multiple occasions as the staff held the medication based on outdated orders. The Assistant Director of Nursing confirmed that the insulin should not have been held without clarifying the new orders with the physician. A third resident, also cognitively intact, had orders to receive Midodrine for low blood pressure under specific conditions. The medication was administered when the resident's systolic blood pressure was between 90 and 120 mmHg, a range not covered by the existing order. The Assistant Director of Nursing confirmed that the order should have been clarified with the physician to address this gap.
Plan Of Correction
1. Resident 19, 63, 76's orders were clarified with the medical director. 2. Review of residents with tube feed flush order, midodrine hold parameter and insulin hold parameter's were reviewed. Registered Nurse's were educated on clarification of flush orders when tube feeding is discontinued and clarification of hold parameters when therapeutic interchange is made and to review midodrine hold parameters for accuracy. 3. Assistant Director of Nursing or designee will audit three residents with tube feed flush order, midodrine order or insulin with hold parameters weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.