Failure to Follow Physician Orders and Document Required Assessments
Penalty
Summary
The facility failed to follow physician orders and ensure appropriate documentation and notification for three residents with complex medical conditions. For one resident with vascular dementia and hypertension, staff administered lisinopril daily as ordered, but did not record the required blood pressure readings at the time of administration, as specified by the physician's parameters. Interviews with the DON and unit manager confirmed that blood pressures were not documented on the MAR and should have been obtained prior to medication administration. Another resident with chronic heart failure, fluid overload, and severe kidney disease had physician orders for daily weights and as-needed furosemide based on specific weight gain thresholds, with instructions to notify the physician for certain weight increases. Despite documented weight gains exceeding the parameters, there was no evidence that the PRN diuretic was administered or that the physician was notified, as required by the orders. The DON confirmed that staff should have followed the orders for medication administration and physician notification, and documented these actions. A third resident with hypertension, dementia, and diabetes had orders for daily weights and PRN torsemide for weight gains meeting specific criteria. The MAR showed missed daily weights without documentation of refusal or unavailability, and instances where significant weight gains occurred but the PRN medication was not administered. There was also no documentation of physician notification for these events. Facility policies required necessary assessments before medication administration and physician notification for values outside ordered parameters, but these were not followed in the cited cases.