Failure to Follow Physician Orders and Medication Protocols
Penalty
Summary
The facility failed to implement physician's orders and follow established protocols for two residents. For one resident with Parkinson's disease and osteoporosis, staff did not administer Milk of Magnesia on the third day without a bowel movement as required by the facility's bowel protocol, and later failed to provide a suppository when indicated. Documentation showed gaps in following the bowel management protocol, despite clear physician orders and care plan instructions to do so. The Director of Nursing confirmed these omissions during an interview. For another resident with a history of stroke, hypertension, and heart disease, staff administered metoprolol despite a documented allergy to the medication. The nurse did not verify the resident's allergies or consult the pharmacy before retrieving the medication from the emergency box, as required by facility policy. After administration, the allergy was discovered and the resident was sent to the hospital for evaluation. The Director of Nursing confirmed that the required checks were not performed prior to medication administration.