Failure to Follow Physician Orders and Professional Standards in Medication Management
Penalty
Summary
Nursing staff failed to follow or clarify physician orders for multiple residents, resulting in medication administration errors and improper documentation. For one resident, pain patches were applied for longer than the prescribed duration, patches were not dated or initialed upon application, and a patch was applied to an area without a physician order. Staff also documented the removal and reapplication of patches that did not occur, and failed to properly document or reattempt obtaining a resident's weight as ordered. Additionally, as-needed medications were administered together without clarification, contrary to best practice. Another resident experienced a significant increase in antianxiety medication dosage without any alert charting or monitoring for side effects. Orders for medications requiring administration on an empty stomach were not clarified, resulting in the medication being given with other oral medications. In a separate case, a vitamin D supplement was administered daily instead of weekly due to a transcription error, which was only identified after nine days by pharmacy review. Blood sugar checks and insulin administration were performed after a resident began eating, rather than before meals as ordered, potentially affecting blood glucose management. Staff also failed to follow up on recommendations and new orders from outside providers. One resident returned from frequent oncology appointments with an IV catheter and medication pump, but there were no corresponding physician orders or monitoring instructions in the facility record. Staff were unaware of the IV and pump, and did not check for new orders or document recommendations from the oncologist. In another instance, a resident with a 'nothing by mouth' order was documented as having consumed snacks, despite the resident stating they were unable to swallow and did not receive snacks. Finally, an as-needed pain medication order lacked necessary parameters, such as maximum dose in 24 hours, and staff did not clarify or update the order.