Failure to Follow Physician Orders and Professional Standards for Pressure Ulcer and Medication Management
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two residents. For one resident with a history of rhabdomyolysis and multiple pressure injuries, there was a physician order for a low air loss (LAL) mattress to aid in pressure ulcer prevention and treatment. Despite this order, the resident was observed on multiple occasions to be using a regular mattress after being moved to a different room, and the LAL mattress was not transferred with the resident. Documentation in the Medication Administration Record (MAR) incorrectly indicated that the LAL mattress was present, and staff interviews confirmed the mattress was not in use as ordered. For another resident with hypertension and atrial fibrillation, there was a physician order for Metoprolol Tartrate to be administered twice daily, with specific parameters to hold the medication if the systolic blood pressure was less than 100 mmHg or heart rate was less than 60 bpm. Review of the Medication Administration Record revealed that vital signs were not consistently taken before administering or holding the medication on several dates. Additionally, the medication was administered when the resident's blood pressure was below the hold parameter, and on multiple occasions, doses were held even though the vital signs were within the prescribed limits. Staff interviews confirmed these discrepancies and acknowledged that the medication was not administered according to the physician's hold parameters. Facility policies required that physician orders be followed as prescribed and that medications be administered in accordance with prescriber orders, including checking vital signs when necessary. The observed failures to follow these policies and physician orders for both residents resulted in services not meeting professional standards of quality.