Failure to Follow Physician Orders for Diabetic Monitoring and IV Antibiotic Administration
Penalty
Summary
The facility failed to follow physician orders for a resident with diabetes and an infection, specifically by not completing required blood sugar (BS) checks before meals and at bedtime, and by not administering intravenous (IV) antibiotics as ordered. Clinical record review showed that after hospital discharge, the resident had orders for diabetic monitoring and IV antibiotics, but the Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation of the required BS checks. Additionally, the IV antibiotic was only administered once out of five ordered days, with multiple entries noting the medication was not given due to lack of IV access or medication not being available. There was also a failure to notify the physician when the IV antibiotic could not be administered due to the absence of IV access or medication. Nurses' notes documented several instances where the resident's IV was not in place or had been removed, and the antibiotic was not given, but there was no documentation that the provider was notified as required. The resident experienced persistently high blood sugar levels, with several readings above 400, and again, there was no documented notification to the provider as ordered. The resident was eventually re-hospitalized for sepsis and had high blood sugar levels upon readmission. Staff interviews confirmed that the expected protocol would be to clarify orders and notify the provider if medications were unavailable or if there were issues with IV access. The facility's policies and job descriptions require prompt implementation of physician orders and communication with providers regarding changes in resident condition or inability to administer medications. Despite these requirements, the facility did not ensure that physician orders were followed or that the provider was notified of significant issues, contributing to the resident's deterioration and subsequent hospitalization.