Failure to Follow Physician Orders and Ensure Medication Availability
Penalty
Summary
The facility failed to follow physician orders and ensure proper documentation for two residents with significant medical needs. One resident with hypertensive heart disease and heart failure had physician orders for regular weight monitoring, including daily and weekly weights, to support cardiac management. However, the resident's weight was only documented a fraction of the required times, with inconsistent use of codes such as 'NA' and 'code six' without clear definitions. Staff interviews confirmed that weights or refusals were not consistently documented as expected, and there was a lack of clarity regarding the documentation process. Another resident with schizoaffective disorder and drug-induced dyskinesia did not receive prescribed doses of Austedo on multiple occasions due to the medication being unavailable. Documentation showed that the pharmacy was contacted after several missed doses, and there were delays in notifying the primary care provider (PCP) about the missed medication. The resident reported feeling the effects of missing the medication, and staff acknowledged that medications should be ordered in advance to prevent running out, with prompt notification to the PCP when medications are unavailable.