Failure to Ensure Accurate Medication Orders and Timely Therapy Evaluation
Penalty
Summary
The facility failed to ensure accurate medication orders and timely therapy evaluations for two residents. In one instance, a nurse administered Metoprolol 37.5 mg by splitting a 75 mg tablet, despite the physician's order specifying Metoprolol Tartrate 50 mg tablets to be given at a 37.5 mg dose. The nurse and Director of Nursing later confirmed that the physician's order was inaccurate and did not match the medication supplied by the pharmacy, but the order was not corrected until after surveyor intervention. This discrepancy was not identified or communicated to the physician prior to the surveyor's discovery. In another case, a resident with increased coughing was observed eating and coughing during a meal. Orders were placed for a chest x-ray, laboratory tests, and a Speech Therapy (ST) evaluation. While the chest x-ray and labs were completed, the ST evaluation was not performed as ordered. The administrator confirmed that the speech therapy evaluation did not occur until prompted by the surveyor, indicating a delay in following physician orders for therapy assessment.