Failure to Follow Physician's Orders for Medication Administration and Vital Sign Monitoring
Penalty
Summary
The facility failed to ensure that physician's orders were followed for one resident, as evidenced by a review of records, interviews, and facility policy. The facility's policy requires medications to be administered in a safe and timely manner, specifically within one hour of the prescribed time unless otherwise specified. For the resident in question, who had diagnoses including hypertension, chronic kidney disease, major depressive disorder, atrial fibrillation, and vitamin B-12 deficiency, the physician had ordered multiple medications and regular vital sign monitoring. Record review revealed that there was no documented evidence that the resident received their morning medications as ordered over a specified period. Additionally, there was no documentation that the evening doses of metoprolol tartrate ER and potassium chloride were administered on two separate days. The records also showed missing documentation of vital signs on several day and night shifts as ordered. The Director of Nursing confirmed in an interview that the medications should have been administered as ordered, but they were not.