Failure to Implement Physician Orders for Weights and Medication Administration
Penalty
Summary
The facility failed to implement physician orders for four residents, as evidenced by clinical record reviews and staff interviews. For one resident with diabetes mellitus and dysphagia, staff did not complete ordered weights on three specified dates. Another resident with post-traumatic seizures, chronic systolic heart failure, and diabetes mellitus was not weighed as ordered on multiple occasions across three months. A third resident with hypertensive chronic kidney disease and diabetes mellitus was not weighed as ordered on a specified date. Additionally, a resident with congestive heart failure and chronic kidney disease received a medication (metoprolol succinate) outside of the prescribed parameters. The medication was administered twice when the resident's systolic blood pressure was below the ordered threshold, and on two occasions, the medication was either administered or held without documented assessment of blood pressure or heart rate. The Director of Nursing confirmed these failures to follow physician orders during interviews.
Plan Of Correction
Immediate action to correct the alleged deficient practice included notification to MD regarding missed weights on Residents 5, 8, and 9 with weights then taken and documented. The MD was notified of resident 10's BP medication being given outside parameters. An initial audit will be completed by the DON or designee of current residents receiving blood pressure medications with parameters and weight orders to ensure BP medication parameters are followed and weights are taken per MD orders. Licensed nursing staff will be re-educated by DON or Designee on FTag 684 with focus on following physician orders to ensure BP medication parameters are followed and weights are taken per MD orders. The DON/Designee will complete audits of 5 residents for weights and 5 residents on BP medication with parameters to be reviewed that physician order was followed weekly x 8, monthly x 2. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.