Failure to Follow Physician Orders for Weight Monitoring and Medication Administration
Penalty
Summary
Facility staff failed to follow physician orders for two residents, resulting in deficiencies related to treatment and medication administration. For one resident with diagnoses including heart failure, hypertension, acute kidney failure, and acute respiratory failure, there was an active physician order requiring daily weights and notification to the cardiologist if the resident's weight increased by 3 pounds in one day or 5 pounds in one week. The resident's records showed weight gains above these parameters on multiple dates, but there was no documentation that the physician was notified as required. Interviews with nursing staff and review of progress notes confirmed the lack of notification. In a separate incident, another resident with multiple diagnoses, including atrial fibrillation, COPD, lung cancer, congestive heart failure, and hypertension, did not receive prescribed heart and sleep medications on the evening of admission and the following morning. The medication administration record confirmed that trazodone, Eliquis, and midodrine were not administered as ordered, despite these medications being available in the backup supply. The LPN on duty reported being unable to access the medications due to a malfunctioning Omnicell unit but did not attempt to contact the pharmacy, service number, or supervisor for assistance, as required by facility protocol. Both deficiencies were confirmed through staff interviews, clinical record reviews, and review of facility protocols. No documentation or evidence was provided to show that the required actions were taken in either case prior to the survey exit.