Failure to Clarify Physician's Orders for Two Residents
Penalty
Summary
The facility failed to ensure that physician's orders were clarified when needed for two residents. For Resident 29, who has end-stage renal disease and receives dialysis through a fistula, there was an order for hemostats to be placed in the resident's room. However, since the resident does not have a hemodialysis catheter, the hemostats were unnecessary. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that the order did not make sense and should have been clarified. For Resident 73, who also has end-stage renal disease and receives dialysis, there was an order for Midodrine to be administered as needed for hypotension on dialysis days. However, there was no documented evidence that staff obtained the resident's blood pressure to determine the need for the medication. Additionally, it was unclear whether the medication should be administered at the facility or the dialysis center. The Director of Nursing and the resident's physician confirmed that the order should have been clarified to ensure proper administration of the medication.
Plan Of Correction
1. The physician's orders for R29 and R73 have been corrected. 2. The Director of Nursing or designee will audit current physician orders for hemostats for dialysis residents for accuracy and dialysis residents that are ordered midodrine for clarification. The physician orders will be updated with any issue identified of the affected residents. 3. The Director of Nursing or designee will re-educate all licensed professionals on the facility policy and procedure for providing hemostats for dialysis residents if applicable to care and clarification of physician orders for dialysis residents. 4. The Director of Nursing or designee will audit new dialysis resident physician orders for hemostat use if applicable to care and clarification of physician orders for dialysis residents. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.