Failure to Follow Physician Orders for Medication Administration and Vital Sign Monitoring
Penalty
Summary
Facility staff failed to follow physician orders for two residents, resulting in deficiencies related to medication administration and vital sign monitoring. For one resident with hemiplegia and moderate cognitive impairment, staff did not administer a prescribed Lidocaine patch as ordered for myalgia. Electronic medication administration records (eMARs) showed multiple instances where the medication was not given, coded as either 'medication not available' or 'other/see progress notes.' However, there was no supporting documentation in the progress notes to explain these omissions. Interviews with nursing and supply staff revealed inconsistent understanding and documentation practices regarding medication availability, despite evidence that the facility had received regular shipments of Lidocaine patches and maintained a house supply. For another resident, staff failed to monitor and document vital signs every two hours as ordered by the physician in response to abnormal temperature readings and a fever. The resident's care plan included interventions for monitoring vital signs due to potential fluid deficit and hypernatremia. However, review of the clinical record and vital sign logs showed that vital signs were not checked or recorded at the required frequency. Interviews with nursing staff indicated a lack of recall or clarity regarding the frequency of vital sign checks for this resident. The facility's own policy on unavailable medications required immediate action and documentation when medications were not available, but this was not followed. Administrative and nursing leadership were made aware of these findings during the survey, and no further information was provided prior to exit.