Failure to Follow Physician Orders and Medication Management
Penalty
Summary
The facility failed to adhere to physician orders for multiple residents, leading to deficiencies in care. For one resident with severe cognitive impairment, the facility did not apply the prescribed antifungal cream as ordered. Observations revealed the resident was experiencing significant discomfort due to a rash, and interviews with staff indicated that the antifungal cream was not available due to a failure to reorder it after the stock expired. Despite the treatment administration record indicating that the cream had been administered, it was confirmed that the medication was not available, highlighting a lapse in medication management and communication among staff. Another resident, who was cognitively intact and diagnosed with hypertension, did not receive the necessary blood pressure monitoring and medication as needed. The resident's care plan required the administration of Catapres for high systolic blood pressure, but the facility did not document blood pressure readings consistently, nor did they administer the medication when required. Interviews with nursing staff revealed inconsistencies in the process of monitoring and documenting blood pressure, which contributed to the oversight in providing the necessary medication. Additionally, the facility failed to follow through with a physician's order for a urology consultation for a resident with an indwelling catheter and a diagnosis of hemorrhagic cystitis. The resident's records showed no documentation of a follow-up with urology, nor any indication that the resident refused the consultation. The Director of Nursing acknowledged the oversight, indicating a failure in ensuring that critical follow-up care was arranged and documented for the resident.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. The was obtained from the vendor and provided the unit on in the afternoon. Resident #5 was provided with the cream as ordered. The Physician for Resident #5 was notified and will continue with treatment plan. Resident #5 had physician and family notified of medication omissions and new orders received for medication administration with no negative outcomes to the patient. Nurse D, Staff F, and Unit Manager were re-educated on the process of following physician orders and timely ordering of supplies. Central Supply Clerk re-educated on timely ordering of supplies. 2. Resident #58 medication was given as ordered. Medication review completed by physician and the continued to be as needed Q 8 hours. Order provided to monitor 3 times/day and as needed. Licensed nurses re-educated on documenting the for Resident #58 every eight hours as ordered and PRN. 3. Resident #63's consultation was rescheduled from to per family request. The physician was notified of the change of the consultation date. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: A facility-wide audit was completed for current residents to identify any other residents affected by the deficient practice. No other residents were affected by the deficient practice. Current residents' Treatment Administration Records have been audited by the Director of Nursing/designee to ensure compliance with following physicians' orders. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Licensed nurses will be re-educated on the importance of following physician orders related to Quality of Care including customer service, monitoring, and follow-up care for those residents with rashes, medication monitoring, ensuring consultations are scheduled timely. Compliance will be monitored through audits three times a week, four weeks, and weekly thereafter to ensure the practice does not recur. 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 in place: The Director of Nursing/designee will conduct treatment observations and consultation audits weekly for four weeks and then monthly for two months to ensure continued compliance. The Director of Nursing/Designee will report the findings of the audits to the QAA&C monthly times three months or until substantial compliance is met.