Failure to Clarify Medication Orders and Monitor Labs
Penalty
Summary
Surveyors identified that the facility failed to ensure physician orders for pain medications were clear and included necessary parameters, such as dosing and pain level indications, for multiple residents. For example, one resident had orders for both over-the-counter and opioid pain medications, but the orders did not specify at what pain levels each medication should be administered. Staff administered medications outside of the prescribed parameters and did not clarify ambiguous orders with the provider. Another resident had a pain patch order lacking dosage and application site instructions, which staff also failed to clarify. Additionally, the facility did not obtain or monitor laboratory values for medications that require lab monitoring. Residents receiving cholesterol-lowering medications, high-dose supplements, and thyroid medications did not have corresponding lab results in their records to ensure the medications were safe and effective. Staff interviews confirmed that these labs were not obtained, despite the expectation that they should be. The facility also failed to ensure that pain management included nonpharmacological interventions and that staff monitored for signs and symptoms of hypo- or hyperglycemia in residents with diabetes. One resident with diabetes reported frequent symptoms of low blood glucose, and there was no documentation of staff monitoring for these symptoms or implementing nonpharmacological pain interventions. Staff confirmed that these practices were expected but not followed.