Failure to Implement Provider Orders and Respond to Abnormal Clinical Findings
Penalty
Summary
The facility failed to implement and document new medication orders and to recognize and respond to abnormal clinical findings for two residents. For one resident with a history of heart failure, hypertension, and other significant comorbidities, a provider issued a new order to increase the dose of furosemide due to weight gain and fluid retention. The order, sent via fax and email, was not entered into the electronic medical record (EMR) or administered as prescribed. Facility staff did not clarify the order with the provider or follow up over the weekend, resulting in the resident not receiving the intended increased dose. Documentation and interviews confirmed the order was missed, and the facility's policy requiring double verification and communication of new orders was not followed. For another resident with hypertension and renal insufficiency, the facility failed to administer as-needed (PRN) antihypertensive medication despite multiple blood pressure readings that met the criteria for intervention. The resident's medication administration record showed that the PRN medication was never given, and there was no documentation of provider notification or alternative interventions for the elevated blood pressures. Staff interviews confirmed that the process for responding to abnormal blood pressure readings was not followed, and the director of nursing acknowledged that each missed dose constituted a medication error. Facility policies required prompt transcription and verification of new orders, as well as immediate provider notification and intervention for changes in resident condition. In both cases, the facility did not adhere to these policies, resulting in failures to provide care and treatment according to provider orders and the residents' clinical needs.