Failure to Ensure Physician Sign-Off on Medication Order
Penalty
Summary
The facility failed to ensure that a medication order for Resident R52 was signed off by a physician before administration, leading to a deficiency in physician supervision. Resident R52, who had diagnoses including heart failure, high blood pressure, and stage 4 chronic kidney disease, was prescribed cefpodoxime, an antibiotic, to be administered twice daily. However, the order was created and confirmed by a registered nurse without a physician's review and confirmation. This oversight resulted in the resident receiving the medication from February 2 to February 13 without proper physician oversight. During this period, Resident R52 experienced acute gastrointestinal pain, diarrhea, and bloating, which were evaluated by a CRNP who suspected the antibiotics might be contributing to these symptoms. Despite these concerns, the resident continued to receive the medication until February 14, when they were transferred to the hospital after repeatedly calling 911 due to severe pain. The hospital confirmed the resident's admission with a diagnosis of pyelonephritis. Interviews with facility staff, including the CRNP and the Director of Nursing, revealed a lack of clarity and adherence to the process for confirming physician orders, contributing to the deficiency.
Plan Of Correction
1. The facility is unable to go back and make certain physician orders were signed off on timely and a resident received treatment and care in accordance with professional standards of practice. Resident R52 is no longer in facility. 2. DON/designee to educate licensed nurses on verifying and implementing physician's orders and need for physician's signatures and verification of new orders prior to medication/treatment administered and notify physicians timely with change of conditions. 3. DON to audit physician's orders/new orders, medication prior to implementation of new orders and timely notification of change in conditions 3x/week for 2 weeks, then 1x/week for 2 weeks. 4. Results to be submitted to QAPI for review and approval.