Failure to Follow Physician Orders for Medications, Insulin, and Tube Feedings
Penalty
Summary
The facility failed to ensure physician orders were followed for four residents in areas including medication administration, insulin management, and tube feedings. For one resident with heart failure, a fluid restriction was discontinued per physician order with instructions to reinstate it if certain symptoms occurred. However, the facility did not consistently monitor the resident for weight gain, edema, or breathing difficulties as required, and did not clarify with the physician whether monitoring parameters were still necessary after daily weights were discontinued. Another resident with end-stage kidney disease and Type I diabetes experienced multiple episodes of severe hypoglycemia and hospitalizations. The facility did not maintain standing orders for glucagon injections, failed to administer glucagon when blood glucose was critically low, and did not ensure glucagon was available in the emergency kit. Additionally, the facility did not follow through with physician orders to enroll the resident in a continuous glucose monitoring program, despite repeated recommendations and hospital discharge instructions. A third resident experienced medication errors when a provider order to decrease insulin dosage was not followed, resulting in the administration of an incorrect dose. The same resident also had a delay in the initiation of an antibiotic order. For a fourth resident with a feeding tube, a provider order for enteral nutrition was incorrectly discontinued, resulting in missed feedings over several days. In each case, staff acknowledged the errors and confirmed that provider orders were not double-checked for accuracy as expected.