Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician's orders for two residents, leading to deficiencies in their care. For one resident, who was cognitively impaired and receiving opioid pain management, the facility did not follow the prescribed schedule for applying a fentanyl patch. The physician's order specified that the patch should be applied every 72 hours, but records showed it was applied every 48 hours, contrary to the order. This discrepancy was confirmed by the Director of Nursing during an interview. Another resident, who was scheduled for a suprapubic catheter exchange, was supposed to discontinue the use of clopidogrel (Plavix) five days prior to the procedure as per the interventional radiology consultation. However, the medication was administered up to the day of the procedure, which was not in accordance with the medical recommendation. This oversight was also confirmed by the Director of Nursing, indicating a failure to follow the necessary pre-procedure instructions.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #44 and Resident #79 did not suffer any adverse reactions. Resident #44 medication order is accurate. Resident #79 does not have any procedures scheduled at this time that require a medication to be on hold. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit residents who were to have procedures completed in the last two weeks to ensure medications that were to be held were and any medications that were put on hold had dates extended if needed. To prevent a future occurrence, the Director of Nursing/designee will educate licensed nursing staff on how to properly place medications on hold and follow consult recommendations to place medications on hold. To monitor and maintain ongoing compliance, an audit of scheduled procedures and order holds will be completed weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.