Deficiencies in Physician Communication and Medication Administration
Penalty
Summary
The facility failed to ensure timely and appropriate communication and response to physician orders and lab results for two residents. For one resident with a history of dysphagia, epilepsy, neurocognitive disorder, and myeloproliferative disorder, the facility did not respond promptly to a physician's inquiry regarding the resident's hydroxyurea dosage after a concerning drop in white blood cell count was noted. Additionally, the facility did not consistently forward lab results to the hematologist/oncologist in a timely manner, with some results delayed and others not received at all. The facility was unable to provide a policy regarding physician communications or faxes, and interviews confirmed that the standard practice was not followed in these instances. Another resident with dementia, diabetes, and major depressive disorder was not administered an ordered dose of Levaquin for pneumonia as prescribed. The medication was left unattended on the resident's bedside table and not given as required, despite the resident's inability to self-administer medications. The error was discovered the following morning by an LPN, who found the medication cup and reported the incident to the nurse supervisor. The facility's policy directed that medications be administered in a safe and effective manner, which was not followed in this case. These deficiencies were identified through review of clinical records, interviews with staff and physicians, and examination of facility documentation and policies. The failures included lack of timely response to physician requests, delayed or missing communication of lab results to consulting specialists, and improper medication administration practices.