Failure to Follow Physician Orders for Medication Administration and Wound Care
Penalty
Summary
The facility failed to follow physician-ordered parameters for administering hypertension medication for one resident with multiple diagnoses, including essential hypertension, hypertensive heart and chronic kidney disease, atrial fibrillation, and hyperlipidemia. Despite having a physician order to administer Hydralazine HCl 10 mg orally every 8 hours as needed for systolic blood pressure (SBP) greater than 160 mmHg, the medication was not given on multiple occasions when the resident's SBP exceeded this threshold. Review of the Medication Administration Record (MAR) for June and July showed no administration of the medication on these dates. Interviews with nursing staff and the Director of Nursing confirmed that the medication should have been administered according to the order, and staff were unaware of or did not follow the PRN order. Additionally, the facility failed to ensure wound dressing changes were performed as ordered for another resident with a skin tear. The physician's order specified cleansing the skin tear and applying an adaptic and foam dressing every three days. Observations revealed that the dressing on the resident's right lower leg was not changed for at least five days, as indicated by the date on the dressing. Staff interviews confirmed the dressing change was overdue and that there was confusion regarding the correct leg for the order. The Director of Nursing acknowledged that the dressing should have been changed according to the specified frequency.