Failure to Follow Physician Orders and Proper Medication Transcription
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for two residents. For one resident with a history of muscle weakness, bilateral knee osteoarthritis, and a left artificial knee joint, physician orders required the application of a foam dressing to the left heel on specific days and the use of offloading booties at all times while in bed to prevent further skin breakdown. During observation, the resident was found in bed without the prescribed foam dressing and booties, and a deep tissue injury with dark purple discoloration was noted on the left heel. Both the LVN and Treatment Nurse confirmed that the required interventions were not in place at the time of observation. For another resident with diagnoses including diabetes, infection related to cardiac and vascular devices, and a recent dental extraction, the facility failed to accurately transcribe a physician's order for Chlorhexidine Gluconate mouth rinse. The hospital discharge summary specified a 0.12% solution for oral use, but the order was incorrectly transcribed as a 4% solution, which is intended for external wound care. This error was confirmed by the DON, MDS Coordinator, and Consultant Pharmacist, who stated that the 4% solution is not appropriate for oral use and may cause adverse effects such as bitter taste, dry mouth, and oral irritation.