Failure to Follow Physician Orders and Notify Providers Regarding Medication Administration
Penalty
Summary
The facility failed to provide needed services in accordance with professional standards by not following physician orders for multiple residents. For one resident with severe cognitive impairment and multiple diagnoses, including atrial fibrillation, heart failure, and respiratory failure, the facility did not administer three prescribed medications, failed to obtain daily weights as ordered, and administered a medication despite the resident's pulse being below the prescribed parameter. Documentation was missing for several medication administrations and required monitoring. Another resident with severe cognitive impairment and multiple chronic conditions, including coronary artery disease, hypertension, and neurogenic bladder, experienced repeated refusals of several scheduled medications and supplements over multiple days. The facility did not notify the primary care provider of these refusals, both for single instances and for continuous refusals over three days, despite facility policy requiring such notification. The resident subsequently refused all medications, nutrition, and hydration for a period, and was later taken to the hospital by family with a diagnosis of complicated urinary tract infection and altered mental status. Staff interviews confirmed that the primary care provider was not notified as required. A third resident with normal cognition and diagnoses including anemia, atrial fibrillation, and renal insufficiency received medication outside of prescribed parameters, specifically antihypertensive medication when blood pressure or pulse was below the hold parameters. There was also a lack of documentation for vital signs required before administration of these medications, and medications were held without physician orders when no parameters were specified. Staff and administration interviews confirmed that documentation was lacking and that medications were administered or withheld outside of physician orders and facility policy.