Failure to Obtain and Follow Physician Orders for Bed Rails, Blood Sugar, and Medication Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for three residents. For one resident with diabetes, there was a lack of physician orders specifying blood sugar parameters for when to notify the physician of dangerously low levels, despite the resident receiving injectable medication for blood sugar control. Additionally, this same resident had bilateral bed rails in use without a corresponding physician order. Staff interviews confirmed that these orders were missing and acknowledged the importance of having them in place. Another resident with hypertension received blood pressure medication outside of the prescribed parameters, as staff administered the medication even when the resident's systolic blood pressure was below the threshold specified in the physician's order. For a third resident, a physician order for a diuretic included instructions to check blood pressure prior to administration, but these instructions were not transferred to the medication administration record, resulting in staff not checking blood pressure as required. Staff interviews confirmed these deficiencies and the need for clarification of orders.