Failure to Timely Enter Physician Orders Delays Medication Administration
Penalty
Summary
The facility failed to follow nursing standards of practice by not ensuring that physician orders were entered into the Point Click Care (PCC) system upon a resident's admission, resulting in a delay in medication availability and administration. Specifically, after returning from the hospital, a resident with diagnoses including idiopathic pulmonary fibrosis, sleep apnea, and acute and chronic respiratory failure did not have their medication orders entered into PCC for approximately 18 hours. This delay prevented floor nurses from being alerted to scheduled and PRN medications that were due, and the resident did not receive prescribed breathing treatments during this period. Clinical records indicated that the resident experienced shortness of breath and a low pulse oximetry reading of 76% on room air, well below the desired threshold. Nurses had to contact the physician for treatment orders because the necessary medications were not available in the system. The Director of Nursing confirmed that it was the RN's responsibility to enter orders into PCC upon admission and acknowledged the failure to do so in this instance.