Failure to Follow Physician Orders and Timely Medication Administration
Penalty
Summary
Surveyors identified that the facility failed to follow physician orders and protocols for multiple residents. For one resident, an elevated ammonia level was identified, and the physician ordered an increase in Lactulose and a repeat ammonia level in one week. However, the repeat ammonia level was not completed as ordered. Another resident experienced a documented hypoglycemic event with a blood glucose level of 47, but the hypoglycemia protocol, which included specific interventions and monitoring, was not followed as per the physician's orders. The resident's care plan included instructions to follow the hypoglycemia protocol, but documentation did not reflect that these steps were taken. Additionally, a third resident reported not receiving medications on time, and record review confirmed that several medications were either not administered or were given outside the facility's policy window for timely administration. These included oral medications for saliva balance, pancrelipase, cetirizine, prednisone, and insulin, with some doses missed or significantly delayed. The facility administrator and a regional resource RN confirmed these findings, acknowledging that physician orders and protocols were not followed as required.