Failure to Follow Physician's Orders and Document Care
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice for several residents. For Resident 27, the staff did not document obtaining the resident's blood pressure and heart rate before administering Hydralazine, a medication for hypertension, as required by the physician's orders. This oversight was confirmed by the Director of Nursing during an interview. Resident 50 experienced multiple deficiencies in care. The resident was administered Oxycodone HCL for pain on several occasions without the medication being signed out on the controlled medication record. Additionally, the resident did not receive prescribed wound care treatments on specific dates, as confirmed by the Nursing Home Administrator. These lapses indicate a failure to adhere to physician's orders and maintain accurate medication records. For Resident 77, there was no documented evidence that the resident's heart rate was checked before administering Lopressor, a medication for hypertension, as required by the physician's orders. Similarly, Resident 69 did not receive bowel medications according to the physician's bowel protocol, resulting in a lack of documented bowel movements over several days. These deficiencies were confirmed by the Director of Nursing, highlighting a pattern of non-compliance with physician's orders across multiple residents.
Plan Of Correction
1. The identified concerns for R27 and R77 were immediately corrected. The identified concern for R50 and R69 cannot be corrected. 2. The Director of Nursing or designee will audit current resident's antihypertensive medications for correct administration parameters if indicated in the physician order. The Director of Nursing or designee will audit current treatment administration records (TAR) for wound documentation of completion. The Director of Nursing or designee will audit current residents to ensure current bowel movement documentation accuracy. 3. The Director of Nursing or designee will re-educate all licensed professional nurses on the documentation of administration parameters for antihypertensive medications. The Director of Nursing or designee will re-educate all licensed professionals on the procedure for completion and documentation of wound care on the treatment administration record (TAR). The Director of Nursing or designee will re-educate all nursing staff on bowel movement documentation and start of bowel protocol if indicated. 4. The Director of Nursing or designee will audit 25% per unit of all parameters for antihypertensive medications for accuracy of administration. The Director of Nursing or designee will audit 25% of wound care treatment documentation on the treatment administration record (TAR). The Director of Nursing or designee will audit 10% of each unit for correct initiation of bowel protocol if indicated. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.