Failure to Follow, Clarify, and Obtain Physician Orders for Multiple Residents
Penalty
Summary
The facility failed to ensure that physician orders were followed, clarified, and obtained as required for several residents. For four residents, staff did not adhere to physician orders regarding medication administration, including administering pain medications outside of prescribed parameters and without proper documentation of pain levels. In some cases, medications were given for pain levels not matching the physician's specified range, and in others, medications were administered without recording the resident's pain level at all. Additionally, some residents had multiple as-needed orders for similar medications, such as laxatives, without clear instructions on which to use first or how to sequence them, leading to potential confusion among staff. Two residents had physician orders that required clarification but were not addressed by staff. One resident with a feeding tube and an order for nothing by mouth had oral medications ordered, which conflicted with their care plan. Another resident had duplicate orders for similar medications without clear guidance, and staff acknowledged that such orders should have been clarified to prevent medication errors. In another instance, a resident requiring dialysis had incomplete orders that did not specify the necessary details for treatment, and staff did not clarify these orders, resulting in the resident not receiving dialysis as needed. The facility also failed to obtain physician orders prior to providing certain treatments. For example, a nurse applied and changed dressings on a resident's lower legs and knee without any corresponding physician orders. The nurse indicated that the dressings were used for protection, but there was no documentation or order to support this practice. The Director of Nursing confirmed that staff were expected to obtain orders before applying dressings and to monitor skin areas under dressings to prevent skin breakdown.