Failure to Verify Physician Orders for NPO Resident
Penalty
Summary
Staff failed to verify the accuracy of a physician's order for a resident who had a diagnosis of dysphagia following a cerebral infarction and was admitted with a feeding tube. The resident's medical record included a physician's order for NPO (nothing by mouth), yet the Medication Administration Record (MAR) contained orders for oral administration of antibiotics. Licensed nurses documented administration of these medications by mouth over several days. During interviews, the Assistant Director of Nursing confirmed the resident was NPO, and a licensed nurse stated she administered the medications via gastric tube rather than by mouth, but did not clarify the order with the physician. The Director of Nursing acknowledged that the antibiotic orders were written in error and not verified in a timely manner. This resulted in a failure to ensure the accuracy of physician orders and proper maintenance of the resident's medical record.