Failure to Follow Physician Orders for Medication and Wound Care
Penalty
Summary
Facility staff failed to follow professional standards of practice for two residents regarding medication administration and wound care. For one resident with a diagnosis of essential hypertension, physician orders specified that staff should withhold amlodipine and notify the physician if the systolic blood pressure exceeded 180, diastolic exceeded 100, or pulse was less than 50. Despite multiple documented instances where the resident's blood pressure was above 180 and pulse was below 50, staff continued to administer the medication and did not notify the physician as required. Review of the medication administration record and progress notes confirmed that no physician notification occurred during these episodes. For another resident diagnosed with cellulitis in both legs, staff performed wound care on both legs, although physician orders were only present for wound care on the left leg. The resident confirmed that wound care was being performed on both legs, and staff interviews corroborated that wound care was provided to the right leg without a corresponding physician order. The treatment administration record only documented wound care for the left leg, and the Director of Nursing confirmed that staff were expected to obtain orders before performing wound care on the right leg, which was not done. These findings were based on record reviews, staff and resident interviews, and direct observation. The deficiencies involved failure to notify the physician as required by orders and performing wound care without appropriate physician authorization, both of which did not meet professional standards of practice.