Failure to Follow Physician Orders for X-rays and Medication Administration
Penalty
Summary
The facility failed to follow physician orders for two residents. One resident with peripheral vascular disease was admitted in February 2017 and had a physician order for a right hand x-ray on September 10, 2024. Although the initial x-ray was negative for fracture, the resident continued to experience pain and limited range of motion, prompting repeat x-ray orders on September 18 and September 24, 2024, which were not completed. The resident was later found to have a right wrist fracture during a hospital visit on October 10, 2024. The Resident Care Manager confirmed that the ordered x-rays were not obtained as directed. Another resident, admitted in September 2024 with kidney failure, had a physician order for hydrocodone/acetaminophen 5-325 mg to be given three times daily as needed (TID PRN). The medication was started four days after the order was received and was administered on a scheduled basis (TID) rather than as needed, due to a transcription error. This error was identified in a provider note, which indicated that the incorrect administration may have contributed to the resident's increased confusion. The Resident Care Manager acknowledged the delay in starting the medication and the incorrect administration schedule.