Failure to Follow Provider Orders and Professional Standards in Medication Administration and Monitoring
Penalty
Summary
Nursing staff failed to follow provider orders and professional standards of quality in the care of three residents. For one resident with severe cognitive impairment and multiple diagnoses, staff did not accurately monitor and document sleep patterns as ordered. Observations showed the resident sleeping during the day, but the medication administration record (MAR) reflected inaccurate or incomplete documentation of sleep hours, with staff admitting to recording sleep data before the end of their shift rather than at the required time. Interviews with nursing staff and management confirmed that documentation was not being completed according to expectations or provider orders. For another resident with quadriplegia and ventilator dependence, staff administered midodrine for low blood pressure even when the resident's systolic blood pressure was above the threshold specified in the provider's order, both in the current and previous months. Additionally, a third resident with metabolic encephalopathy and mood disorders had overlapping orders for two different concentrations of lidocaine cream, and staff failed to discontinue the previous order as required when the new order was received. In each case, staff and management acknowledged that provider orders were not followed, resulting in medication administration and monitoring errors.