Failure to Follow Physician Orders for Medication Administration and Skin Protection
Penalty
Summary
The facility failed to provide care and treatment in accordance with physician orders for two residents. For one resident with a history of atrial fibrillation and hypertension, Metoprolol Succinate ER was administered on multiple occasions despite the resident's apical pulse being below the physician-ordered threshold of 60 beats per minute. There was no documentation explaining why the medication was given outside of the specified parameters, and staff interviews confirmed there was no reason for this deviation from the order. Another resident, who was prone to easy bruising and had a physician's order for Geri-sleeves to be applied to both arms every shift for skin protection, was repeatedly observed without the sleeves in place. The resident reported not having the sleeves applied for several days and denied refusing them. When sleeves were eventually applied, they were ill-fitting and slid down to the wrists, failing to provide the intended protection. These findings were confirmed through observations and interviews with the resident and facility staff.