Failure to Obtain Physician Orders and Administer Medications as Ordered
Penalty
Summary
The facility failed to obtain a physician's order for foley catheter care for one resident and failed to follow physician orders for another resident, as evidenced by policy review, medical record review, observations, and interviews. For one resident, there was no physician order for the placement or care of an indwelling urinary catheter, and no documentation of the catheter's insertion was found in the medical record. Additionally, enhanced barrier precautions, which are required for residents with indwelling medical devices, were not ordered or implemented, and there was no signage indicating these precautions in the resident's room. Staff interviews confirmed the absence of required orders and documentation. Another resident, who was severely cognitively impaired and dependent for all activities of daily living, had multiple diagnoses including diabetes, hypothyroidism, and a history of psychotic disorder. Review of this resident's medication administration records (MAR) over several months revealed numerous instances where scheduled medications, including insulin, levothyroxine, divalproex, megestrol acetate, and risperidone, were not administered as ordered. There was no documentation or explanation for the missed doses, and the MAR contained multiple blanks for scheduled medication administrations. The DON confirmed that unsigned medication administrations should be considered as not given. The deficiencies were identified through a combination of policy review, medical record review, direct observation, and staff interviews. The lack of physician orders for catheter care and enhanced barrier precautions, as well as the failure to administer and document scheduled medications, were not in accordance with facility policy or physician instructions. These findings were confirmed by staff, including the DON and nursing staff, who acknowledged the absence of required documentation and orders.