Failure to Follow Physician Orders for Medication and Blood Sugar Monitoring
Penalty
Summary
The facility failed to follow physician orders for two residents. For one resident, there was an order to administer Levofloxacin 750 mg by mouth every 48 hours, starting on 4/2/25 and ending on 4/22/25. However, the medication administration record showed that the resident received doses on consecutive days, 4/2/25 and 4/3/25, rather than every 48 hours as ordered. Interviews with two LPNs revealed that the facility's Pyxis system did not have the required dose, and they expected the medication to arrive the next morning, but the resident still received the medication two days in a row, not in accordance with the provider's order. For another resident, the treatment administration record indicated a blood sugar result of 422, which required 12 units of insulin and a call to the medical doctor per the sliding scale insulin protocol. The clinical record confirmed that the MD was called, and an additional order was given to administer 3 more units of insulin and to recheck blood sugar in 2 hours. However, there was no evidence in the clinical record that the blood sugar was rechecked as ordered.