Failure to Follow Physician Orders for Consults and Medication Administration
Penalty
Summary
The facility failed to ensure that physician orders were followed and that residents received appropriate treatment and care according to those orders and the residents’ preferences and goals. For one resident with chronic dermatological concerns, a nurse practitioner ordered a dermatology consult to address ongoing skin issues. Although the order was confirmed by nursing staff, the consult was never scheduled. The medical records/unit clerk admitted to not scheduling the appointment and could not provide a reason for the omission, despite the resident’s repeated requests and ongoing skin concerns. Another resident, who was readmitted from the hospital, did not receive multiple prescribed medications for several days. The resident reported going days without medications upon return to the facility. Medical record review confirmed that numerous medications, including those for seizures, pain, rash, and other chronic conditions, were not available or administered as ordered. Documentation showed repeated notations of medications being on order, awaiting pharmacy delivery, or not available, spanning several days and affecting a range of essential treatments. Interviews with facility staff, including the DON, revealed that there were established processes intended to ensure medication availability, such as using backup supplies and expedited pharmacy delivery. However, these processes were not effectively implemented, resulting in significant lapses in medication administration. The failure to schedule a specialist consult and to provide timely access to prescribed medications directly contravened physician orders and the standard of care expected for residents.