Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
The facility failed to follow physician orders and professional standards of practice for two residents. For one resident with diabetes and a history of slow wound healing, staff did not implement the physician's order to cleanse and treat both legs and ensure the resident's feet were placed in protective boots while in bed. Observations showed the resident's legs were not off-loaded as required, and the boots were not in use, despite the resident expressing a preference and expectation to wear them for wound protection. A licensed nurse confirmed the order was not followed and acknowledged the potential for the resident's condition to worsen if the treatment was not implemented. For another resident with multiple diagnoses including GERD, a nurse was observed pre-pouring medications into multiple cups and preparing to administer Donepezil before the scheduled time, contrary to physician orders and facility policy. The nurse also left unlabeled medication cups in the medication cart. The RN supervisor confirmed that medications should be prepared and administered for one resident at a time, at the correct time, and that pre-pouring and leaving unlabeled medications was not acceptable. Facility policies reviewed supported these expectations for medication administration.