Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician orders for two residents regarding medication administration. For one resident with hypothyroidism and diabetes, a physician order for levothyroxine to be given once daily via feeding tube was incorrectly transcribed as three times daily. As a result, the resident received three doses on one day and two doses on the following day, instead of the prescribed single daily dose. The error was identified in the medical record and confirmed by a physician progress note, but the administrator provided no additional information when informed of the findings. For another resident with a history of above-the-knee amputation and diabetes with neuropathy, multiple doses of prescribed insulin lispro were missed over two consecutive days. The orders included both scheduled and sliding scale insulin doses, but documentation revealed that several doses were not administered as ordered. An LPN discovered the missed doses and reported the issue to the Director of Nursing Services. The administrator was also informed of these findings and did not provide further information.