Failure to Follow Physician Orders and Timely Notify of Weight Loss
Penalty
Summary
The facility failed to follow physician orders and provide appropriate treatment and care for two residents, leading to deficiencies in quality of care. For one resident, the facility did not administer the prescribed medication, Empagliflozin, on multiple occasions due to delays in delivery from the pharmacy. The Director of Nursing confirmed that the medication was not administered on the specified dates and that the physician was not notified of these missed doses. Another resident experienced significant weight loss, which was not promptly communicated to the physician. The resident's weight dropped from 119.5 lbs to 108.6 lbs in one month, and further to 101.5 lbs over three months, indicating a 15% loss. Despite this, the physician was not informed until a month later, delaying necessary interventions. The resident's tube feeding formula was not adjusted in a timely manner, as the facility waited to exhaust the existing supply before implementing the physician's verbal order for a change. Interviews with facility staff confirmed these lapses in care. An LPN Assessment Coordinator acknowledged the delay in notifying the physician about the weight loss and the subsequent delay in changing the tube feeding formula. These actions and inactions demonstrate a failure to adhere to professional standards of practice and timely implementation of physician orders, as required by the facility's policies and regulations.
Plan Of Correction
Resident 23 medications arrived from pharmacy and administered per orders. All residents' medication cards were evaluated to ensure medications are available. Nursing staff will be educated by the Director of Nursing or designee on ensuring that medications are available and the need to reorder is completed timely, as well as physician notified when medication are not given. Night shift will check medication carts for need to reorder medication before quantity is low. Charge nurse will check daily if meds are not available or not received, with unit nurse, to ensure they are ordered and MD aware. Audits will be completed that nurses reorder medications timely and MD notification for medication not received. The Director of Nursing or a designee will audit for medications that quantity is sufficient weekly for a month. Bi-weekly for a month and monthly thereafter. All results will be reviewed at QAPI. Resident 36 MD aware of weight loss. Dietician restarted on 11-6-2024. Dietician reviewing all weights and notifying physician timely. All residents reviewed for weight loss and MD updated as indicated. Changes in orders implemented on recommendation. Dietician educating nursing on notifying MD on weight loss and changing orders for tube feeding on recommendation. QAPI for Weight loss MD notification and change in orders will be done by the dietician or designee, weekly for one month, bi-weekly for one month and monthly thereafter. All results will be reviewed with the QAPI committee.