Failure to Provide Care According to Physician Orders and Professional Standards
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure, atrial fibrillation, and hypertension was admitted following a hospitalization for dyspnea. Upon admission, the facility transcribed a hospital order for Carvedilol incorrectly, entering it as 25 mg twice daily instead of the intended 12.5 mg (half tablet) twice daily. This error resulted in the resident receiving double the prescribed dose for four administrations, leading to hypotension, acute kidney injury, and a transfer to the hospital. The facility's admission process was not followed, as the required admission checklist and second nurse review were not completed, and the error was not identified by the pharmacist during the admission medication review. Another deficiency was identified when a resident with a history of unstable angina and an order for sublingual nitroglycerin for chest pain reported chest pain during the night. Instead of administering the prescribed nitroglycerin, staff gave the resident an antiemetic (Zofran) and did not assess the resident for a change in condition or notify the attending provider. The resident later requested transfer to the hospital for evaluation of a possible heart attack due to their medical history. A third deficiency involved a resident admitted after a hospitalization, for whom the facility failed to obtain and document weights as ordered. The resident's care plan and physician orders required weights to be taken on admission, on day two, and weekly for four weeks. Documentation showed that weights were not obtained or recorded on the required days, and there was no evidence that attempts were made to obtain the missing weights. The DON was unable to account for the missing documentation or explain why the required weights were not obtained.