Failure to Follow Physician Orders for Medication and Therapy
Penalty
Summary
The facility failed to follow physician's orders for two residents. For one resident with diagnoses of hypertension, diabetes, and obesity, the Treatment Administration Record did not show documentation that Ozempic, a GLP1 medication, was administered as ordered on 4/4/25. Progress notes indicated the medication was expected from the pharmacy that evening, but there was no further documentation confirming its receipt or administration. Staff interviews confirmed the medication was missed because it did not arrive from the pharmacy, and the facility lacked a policy related to following physician orders. For another resident with diagnoses of hypertension, depression, and dementia, a physician ordered physical therapy (PT) evaluation and treatment after the resident expressed a desire to use the therapy bike. However, the clinical record did not show that PT was provided following the order. Staff interviews revealed that nursing staff are responsible for notifying the contracted therapy group of new orders, but the order for PT was missed and not communicated, resulting in the therapy not being initiated.