Failure to Administer and Document Physician-Ordered Treatments and Notify Provider of Critical Lab Results
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for two residents. For one resident with chronic conditions including COPD, diabetes, and dementia, the facility did not document administration of a prescribed Betadine treatment for a toe wound on a specific date, as required by the care plan and treatment administration record (TAR). The responsible LVN confirmed the absence of documentation and stated that the treatment was not recorded as given, which was contrary to facility policy requiring all topical treatments to be documented on the TAR. Additionally, the same resident had physician orders for regular blood sugar (BS) monitoring and specific instructions for notifying the provider if certain BS thresholds were met. Despite multiple elevated BS readings over several days, there was no record of provider notification as required by the order. Both the LVN and an RN confirmed that the provider should have been notified of these results, and the facility's diabetes protocol required staff to report such findings. For a second resident with diagnoses including anxiety disorder, alcoholic cirrhosis, and splenomegaly, the facility failed to document administration of a prescribed topical antibiotic (Mupirocin) for a toe infection on a specific date. The LVN confirmed the lack of documentation on the TAR, indicating the treatment was not recorded as administered. Facility policy required all medications, including topical treatments, to be administered as prescribed and documented accordingly.