Failure to Follow Physician Orders and Complete Required Assessments
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for one resident. During medication pass, a nurse was unable to locate the prescribed Albuterol inhaler for a resident with chronic obstructive pulmonary disease and did not administer the 9 a.m. dose as ordered. The nurse did not notify the physician about the missed dose, and the medication was still not given nearly three hours later. The resident, who was cognitively intact and receiving oxygen, confirmed that the breathing treatment had not been received as scheduled. Facility policy required that medication errors, including omissions, be reported to the Director of Nursing, attending physician, and administrator. The facility also failed to complete vital sign assessments after seizure episodes for another resident. A family member reported that the resident appeared distressed and had a fever prior to experiencing multiple seizures. Documentation showed that vital signs were only taken before the seizures, with no record of vital signs or temperatures being taken after the episodes. Nursing staff confirmed that post-seizure vital signs were not documented or performed, and the Director of Nursing acknowledged that documentation of seizure times and post-episode vital signs was missing. Facility policy required that vital signs be obtained and recorded after seizure activity, along with detailed documentation of each episode. Additionally, the facility did not follow physician orders for the use of a foot cradle for a resident with a wound. The resident reported never having a foot cradle, and nursing staff confirmed that the device was not in use, despite a standing physician order for its use every shift. Review of facility policy indicated that supplies and equipment required to carry out physician orders should be provided and verified for completeness and accuracy.