Failure to Follow Physician Orders for Medication and Pressure Ulcer Equipment
Penalty
Summary
A review of clinical records and staff interviews revealed that the facility failed to follow physician's orders for one resident. The resident, who was cognitively intact and required staff assistance for daily care, had diagnoses including paraplegia, wound infection, and a Stage 4 pressure ulcer. Physician's orders specified that the resident was to receive 4.5 grams of Piperacillin-tazobactam intravenously every eight hours. However, the Medication Administration Record showed no documented evidence that the resident received the antibiotic as ordered on three occasions within a specified day. Additionally, the resident requested bed rails and an air mattress for repositioning and pressure ulcer management. A wound consult by a CRNP recommended an air mattress for the resident's pressure ulcers. Despite these recommendations and requests, there was no documented evidence in the clinical record that the resident received an air mattress. The Director of Nursing confirmed that the resident did not receive the IV antibiotic as ordered and that there was no documentation of the air mattress being provided.