Failure to Follow Physician Orders and Vaccination Protocols
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and that vaccinations were provided in a timely manner with proper informed consent. For one resident, antihypertensive medications (amlodipine and metoprolol) were administered despite a diastolic blood pressure below the threshold specified in the physician's order, which required the medications to be held. Staff confirmed that the medications should have been withheld as per the order. Additionally, multiple residents experienced deficiencies related to the administration of Covid vaccinations. In several cases, there was a lack of timely administration following consent, missing documentation of risk/benefit discussions, and failure to provide or document the Vaccine Information Statement (VIS). Some residents did not receive the vaccine for months after consent, and in one case, a resident's refusal was not accompanied by documentation that risks and benefits were reviewed. Staff interviews confirmed that these actions did not meet facility expectations for timely vaccination and informed consent procedures.