Failure to Follow Physician Orders and Document Care for Multiple Residents
Penalty
Summary
The facility failed to provide care and treatment in accordance with physician orders and professional standards for multiple residents. For one resident with essential hypertension, Metoprolol was administered on several occasions despite blood pressure and heart rate readings falling below the physician-ordered parameters. There was no documented evidence explaining why the medication was given outside of these parameters, and the care plan required monitoring for side effects and effectiveness, which was not documented. Another resident with diabetes had repeated blood glucose readings significantly above the physician-ordered threshold that required staff to notify the physician if blood sugar exceeded 400 mg/dL. Despite numerous instances of elevated blood sugar, there was no evidence that the physician was notified as required by the orders. Additionally, there were several entries where staff documented 'NA' instead of recording blood sugar values or actions taken, indicating a lack of proper monitoring and documentation. A third resident with an open area on the right buttock had a physician's order for daily wound care using Medihoney and border gauze. However, there was no documented evidence that a skin assessment was completed to determine the status or measurement of the wound, nor was there documentation on the MAR or TAR to confirm that the treatment was administered as ordered. These deficiencies were confirmed during interviews with facility leadership.