Failure to Follow Physician Orders for Medication and Compression Stockings
Penalty
Summary
Staff failed to follow physician orders for two residents. For one resident with Parkinson's disease and hypotension, a physician ordered midodrine hydrochloride to be administered three times daily, to be withheld if the systolic blood pressure (SBP) exceeded 140 mm/Hg. Review of the medication administration record showed that staff administered the medication on three occasions when the resident's SBP was above 140 mm/Hg, contrary to the order. Additionally, the medication was withheld twice in May when the resident's SBP was below 140 mm/Hg, when it should have been given. For another resident with heart failure and diabetes, a physician ordered compression stockings to be applied in the morning and removed at bedtime. Observations on multiple occasions revealed that the resident was not wearing the compression stockings as ordered. The resident and a family member confirmed that the resident had not worn the stockings since admission, except for one observed instance. The facility administrator confirmed these findings during interviews.