Delay in Entering Physician Orders Led to Missed Respiratory Treatments
Penalty
Summary
The facility failed to enter a physician's medication orders in a timely manner for a resident who returned from the hospital. According to facility policy, medications are to be administered safely, timely, and as prescribed. However, after the resident was readmitted with diagnoses including idiopathic pulmonary fibrosis, sleep apnea, and acute and chronic respiratory failure, their medication orders were not entered into the electronic health record system (PCC) until approximately 18 hours after their return. This delay meant that floor nurses were not alerted to scheduled or PRN medications that needed to be administered. During this period, the resident experienced an episode of respiratory distress, with a documented oxygen saturation of 76% on room air, which is below the desired level. The resident reported not having received any breathing treatments since returning from the hospital. The necessary medications, including Albuterol and Budesonide, were not available for administration during the episode because the orders had not been entered. The DON confirmed that the delay in entering the physician's orders resulted in a delay in treatment for the resident.