Failure to Follow Physician Orders for Specialized Care and Medication Administration
Penalty
Summary
The facility failed to provide necessary care and services as ordered for several residents. One resident with a history of benign prostatic hyperplasia and obstructive and reflux uropathy was admitted with a Foley catheter and had discharge orders specifying that a void trial should be performed under urology supervision. Despite this, the void trial was conducted at the facility without urology supervision, and the resident subsequently experienced a high post-void residual and discomfort during repeated unsuccessful straight catheterizations, ultimately requiring transfer back to acute care for Foley catheter placement. The director of nursing confirmed that the void trial should have been supervised by urology as per the discharge orders. Additionally, the facility did not administer blood pressure medications according to physician orders for three residents. One resident received hydralazine when their systolic blood pressure (SBP) was below the ordered threshold and did not receive it when their SBP was above the threshold on multiple occasions. Another resident did not receive hydralazine when their SBP exceeded the ordered limit, and a third resident was given losartan potassium despite an SBP below the hold parameter. The director of nursing reviewed the medication administration records and confirmed these discrepancies. Facility policy and job descriptions require that medications be administered according to practitioner orders, which was not followed in these instances.