Failure to Follow Physician Orders for Medication Administration and Laboratory Testing
Penalty
Summary
The facility failed to ensure that services provided or arranged met professional standards of quality for two residents in relation to following physician orders. For one resident with a history of traumatic brain injury, bipolar disorder, anxiety disorder, major depressive disorder, and behavioral syndromes, there was a new order for Depakote 250mg twice daily for mood stabilization following discharge from a psychiatric hospital. The medication was not administered as ordered; the resident did not receive the evening dose on the day of return or the morning dose the following day. Staff interviews revealed confusion regarding the medication order's start date, lack of documentation on the MAR, and a failure to notify the physician of the missed dose. The medication was available in the emergency supply, but it was not given, and the pharmacy had not received a request to fill the medication prior to staff inquiry. For another resident with diagnoses including pyelonephritis, head injuries, and quadriplegia, the physician ordered a UTI Panel to be obtained prior to starting antibiotics. The order was documented, but there was no evidence in the medical record or laboratory results that the urine specimen was collected before the initiation of antibiotics. Staff interviews confirmed that the UTI Panel was not obtained as ordered, and the physician was notified after the fact. The specimen was eventually collected and processed several days later, but not in accordance with the original physician order. In both cases, the facility did not follow physician orders as outlined in the residents' comprehensive care plans. There was a lack of documentation, communication, and timely action by nursing staff, resulting in the failure to administer medication and obtain required laboratory specimens as prescribed.