Failure to Follow Physician Orders and Manufacturer Instructions for Medication and Wound Care
Penalty
Summary
The facility failed to follow physician's orders and manufacturer instructions for medication administration, as well as wound care recommendations, for three residents. One resident, who was cognitively intact and had diabetes, received Humalog insulin on multiple occasions despite blood sugar readings below the threshold specified in the physician's order, which required the insulin to be held if blood sugar was less than 100 mg/dL. Another resident, also cognitively intact and with diabetes, received Humalog insulin at times not aligned with the manufacturer's instructions, which state the medication should be administered within 15 minutes before or immediately after meals. The insulin was given at times that did not correspond with scheduled meal times. Additionally, a resident with cognitive impairment and frostbite wounds to the toes did not receive wound care as recommended by a wound consultant. The consultant recommended betadine be applied to the first and second toes of both feet twice daily, but physician's orders only included the right foot, and there was no documentation that the left toes received the recommended treatment. These deficiencies were confirmed through review of clinical records, medication and treatment administration records, and interviews with facility leadership.