Failure to Clarify and Follow Physician Orders and Accurate Documentation
Penalty
Summary
The facility failed to ensure that physician orders were properly clarified and followed, and that staff only signed for tasks that were actually completed, as evidenced by multiple observations, interviews, and record reviews. For several residents, medication orders lacked necessary parameters or dosage information, such as pain medication orders without pain level parameters, a suppository order referencing a laxative that was not ordered, and supplement orders missing dosage amounts. Additionally, there was a failure to document required assessments, such as not recording heart rates before administering blood pressure medication, and staff confirmed that these orders required clarification. Further deficiencies included staff administering medication outside of prescribed parameters, such as giving blood pressure medication when a resident's heart rate was below the specified threshold. Staff also documented completion of tasks that were not performed, including recording the removal of a chest brace for a resident who was no longer using it and documenting contact precautions for a resident who was not on such precautions. These actions were confirmed through staff interviews and record reviews, indicating a lack of adherence to professional standards and facility policy.