Failure to Follow Physician's Orders for Medication and Weight Monitoring
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with professional standards of practice. For Resident 15, who was cognitively impaired and diagnosed with hypertension, the facility did not adhere to the physician's orders regarding the administration of Labetalol. Despite the order to withhold the medication if the resident's heart rate was below 50 beats per minute, the medication was administered on two occasions when the heart rate was 44 bpm and 47 bpm, respectively. Additionally, the facility did not follow physician's orders for Residents 70 and 95 regarding weight monitoring and physician notification. Resident 70 experienced a 4.4-pound weight gain overnight, but there was no documented evidence that the physician was informed. Similarly, Resident 95 had a significant weight gain of 47.8 pounds over a few days, yet the physician was not notified. These failures were confirmed through staff interviews, indicating a lack of adherence to prescribed care protocols.
Plan Of Correction
Resident 15 had no adverse reactions to having an antihypertensive medication (a medication that treats hypertension) administered outside of heart rate parameters set forth by the physician. The physician was made aware of the medication administration outside of the parameters. Resident 70 had no adverse reactions to not having the medical doctor (MD) notified of a weight gain in one day. The resident is no longer in the facility. Resident 95 had no adverse reactions to not having the MD notified of a weight gain in one day. The resident is no longer in the facility. Facility-wide sweep for all residents who have heart rate parameters with antihypertensive medications to ensure that heart rate parameters were followed according to physician order was conducted. Facility-wide sweep for all residents with significant weight loss was conducted to ensure proper physician notification. Any issues identified were corrected at time of discovery. All licensed nursing staff was re-educated on heart rate parameters surrounding antihypertensive medications and notification of physician in addition to significant weight change education. The Assistant Nursing Home Administrator or designee will conduct audits to ensure that heart rate parameters with antihypertensive medications are followed and that all significant weight changes have physician notification, weekly for 4 weeks and then monthly for 2 months. Identified issues will be addressed at time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.