Failure to Follow Physician Orders for Medications and Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders for four residents with significant medical conditions. For one resident with chronic kidney failure, congestive heart failure, and diabetes, staff administered isosorbide mononitrate on multiple occasions when the resident's systolic blood pressure (SBP) was below the physician-ordered threshold of 115 mmHg. Similarly, another resident with hypertension received losartan potassium three times when their SBP was below the ordered hold parameter of 110 mmHg, and a third resident with hypertension was given metoprolol tartrate six times when their SBP was also below 110 mmHg, contrary to physician instructions. These actions were confirmed through medication administration record reviews and staff interviews. Additionally, a resident with partial paralysis following a stroke and chronic respiratory failure with hypoxia was observed without the ordered oxygen therapy. The resident was found in a hallway with an empty oxygen tank and no nasal cannula, despite a physician's order for continuous oxygen administration at two liters per minute. Staff confirmed that the oxygen was not administered as ordered. These findings demonstrate that the facility did not consistently implement physician orders for medication and oxygen therapy for multiple residents.