Failure to Follow Physician Orders and Monitor Resident Status
Penalty
Summary
The facility failed to ensure that physician-ordered parameters for medications were followed for several residents. For example, one resident with a history of stroke and arthritis, who frequently experienced severe pain, was administered as-needed pain medication for a pain level below the physician-ordered threshold. Another resident with a pain disorder and muscle weakness received pain medication outside the specified parameters on multiple occasions. These actions were confirmed through review of medication administration records and staff interviews, which acknowledged that medications were not always given according to the prescribed parameters. The facility also failed to clarify physician orders as needed for residents with complex medication regimens. In one case, a resident with anxiety and heart failure had an order for an antianxiety medication that did not specify when to administer one versus two tablets, and an order to monitor edema that lacked details on which body part to assess or actions to take for severe swelling. Staff interviews confirmed that these orders were unclear and should have been clarified with the provider, but this was not done. Another resident with insomnia had an as-needed supplement order for sleep that lacked clear administration parameters, which staff also failed to clarify. Additionally, the facility did not consistently monitor resident weights as ordered, particularly for residents at risk for malnutrition. One resident with cancer and heart disease experienced a significant, unverified weight loss over one week, with inconsistent weighing methods and no documented re-weigh or physician notification. The facility's policy required re-weighing for significant weight changes and consistent weighing practices, but these were not followed. Furthermore, staff failed to monitor and document edema as ordered for another resident with congestive heart failure, despite observable swelling and resident complaints. Staff interviews confirmed that required monitoring and documentation were not completed.