Failure to Follow Provider Orders for Medication and Procedure Preparation
Penalty
Summary
Facility staff failed to provide treatment and care according to medical provider orders for two residents. For one resident with multiple diagnoses including schizoaffective disorder and COPD, staff did not administer Bacitracin ointment to burns on the face, nares, and right hand as ordered after the resident returned from the emergency department. The medication was not given on a specified day shift, and documentation indicated the nurse was waiting for the ointment from the pharmacy, despite it being available as house stock. The nurse was unaware of this, resulting in the omission of the ordered treatment. For another resident with intact cognition, staff did not follow physician orders for colonoscopy preparation. The resident reported that the facility failed to provide a clear liquid diet and did not administer the prescribed Dulcolax tablets as directed, leading to an incomplete colonoscopy due to inadequate bowel prep. Review of records confirmed that only one dose of Dulcolax was given, and a consult note documented that the facility failed to administer the proper prep according to the patient. The facility's documentation and staff interviews confirmed these failures to follow provider orders.