Failure to Follow Physician Orders and Medication Errors
Penalty
Summary
The facility failed to follow physician orders for multiple residents, leading to several deficiencies. Resident #26 was observed without a required binder, which was supposed to be applied to prevent her from pulling out a medical device. Despite the absence of the binder, the Treatment Administration Record (TAR) was signed off by nursing staff as if the binder had been applied. The binder was reportedly sent to the laundry, and alternative measures were inadequately implemented, resulting in the resident being exposed and the insertion site leaking. Resident #470 received incorrect medication administration, where the nurse administered a medication not ordered by the physician and failed to administer the correct dosage of another medication. The nurse was unaware of the differences in medication strengths and mistakenly believed two medications were the same. This error was confirmed during an interview with the nurse, who acknowledged the mistake in medication administration. Residents #271 and #23 had issues with the timely changing of their medical device covers. The covers were not changed as per the physician's orders, which required changes every seven days. The Medication Administration Records (MAR) inaccurately reflected that the covers were changed, despite photographic evidence and staff interviews confirming otherwise. The Director of Nursing acknowledged the failure to follow physician orders and the incorrect documentation in the MARs.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A. RN staff R and RN staff K was educated on medication administration. B. Residents #26, #23, #271, #470 and #60 no negative outcome was noted. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Audit was completed to ensure residents was receiving correct medications and abnormal finding was corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. License Nurses was educated on F759 documentation and medication administration this education will be provided annually and upon new hire orientation. B. Nursing Managers will audit medication administration for any documentation of such as but not limited to not available, holes/blanks in the MAR and ensure that appropriate follow up was completed. C. Medication competency was completed for current license nurses and any new license nurse hired. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do random audits of license nurses during medication administration to ensure proper procedure/techniques is being utilized weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter. 1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A. Resident #26 binder use was corrected. B. RN staff K educated on documentation. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete audit of resident and any specialty device used for their tube was completed and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. License Nurses was educated on documentation with emphasis on services not provided/ physician orders not carried out and the process of documentation. B. Nurse Manager to review 24 hour report and order detail summary the following business day for any refusal or care, supplies not available and any new order for specialty equipment and follow up to ensure appropriate interventions were implemented. C. Staff was educated on the competence of F693 and this education will be provided upon new hire orientation and annually. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do random audits of resident and any specialty equipment used on their is being utilized weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter. 1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #271 and #23 was changed. B. LPN staff V was educated on change. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with lines and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; A. License Nurses was educated on changes. B. Nursing Management will review 24-hour report and order listing report for any new placement and any refusal of care related to change and follow up to ensure appropriate interventions are being followed. C. License nurses was educated on F694, documentation of care and services provided and refusal of care and services, this education will also be provided during new hire orientation and annually. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do audits of resident receiving s has received their change weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.