Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders, resident preferences, and goals for seven residents. In one case, a resident with multiple diagnoses including cellulitis, amputation, and MRSA did not receive a scheduled dose of Cefazolin antibiotic because the medication was not administered as ordered, despite the medication being available in the STAT box. The nurse on duty did not utilize the available medication, and there was no documentation explaining the omission. Another resident was administered an incorrect dose of Baclofen, receiving 10 mg in the morning instead of the ordered 5 mg. The LPN responsible for the medication pass took the dose from the supply card labeled for bedtime, rather than the correct morning dose, even though the correct medication was available. Additionally, a resident with orders for vital signs every shift did not have these assessments completed on two separate day shifts, with no explanation documented in the clinical record. Further deficiencies included failure to administer insulin as ordered and within the standard time frame, with missed or delayed doses and lack of documentation or physician notification regarding omissions. Several residents with orders for daily weights and physician notification for significant weight changes did not have weights recorded on multiple days, and in some cases, significant weight changes were not communicated to the physician as required. These failures were confirmed through interviews, clinical record reviews, and facility documentation, with no additional information provided by the facility prior to the survey's conclusion.