Failure to Follow Physician Orders and Professional Standards in Medication and Oxygen Administration
Penalty
Summary
The facility failed to provide treatment and care to several residents in accordance with professional standards of practice and physician orders. One resident with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and chronic kidney disease (CKD) was observed receiving continuous oxygen therapy at 4 liters per minute without a physician's order. The resident's medication administration record (MAR) and order summary did not reflect an order for oxygen, although the care plan referenced oxygen therapy. The Director of Nursing (DON) confirmed that the resident was using oxygen without a physician's order, contrary to facility policy and professional standards. Another resident with osteomyelitis, a stage 4 pressure ulcer, polyneuropathy, and bipolar disorder did not receive their prescribed Lyrica medication for five consecutive days due to a pharmacy delivery issue. The MAR indicated the medication was held, but there was no physician order to hold it, and the care plan required administration per physician orders. The DON and a registered nurse confirmed that the pharmacy was notified but no follow-up occurred to obtain the medication, and the physician had not ordered the medication to be held. Additional deficiencies included failure to change and label oxygen tubing weekly as required by both care plans and facility policy for two residents, and failure to follow a physician's order for wound care for another resident. In one case, a nurse used table salt instead of Epsom salt for a prescribed soak, which was confirmed by the DON. In another case, oxygen tubing was not labeled or dated as required, and staff interviews confirmed inconsistent practices regarding tubing changes and labeling.