Failure to Timely Implement Provider Orders for Medication and Treatment
Penalty
Summary
A resident with a history of acute on chronic diastolic congestive heart failure, edema, paroxysmal atrial fibrillation, and acute embolism and thrombosis of the lower extremities was re-admitted to the facility. The resident experienced chest pain, generalized pain, weakness, fatigue, and symptoms suggestive of a urinary tract infection and shortness of breath. Following a provider assessment, new orders were given, including an extra 20 mg of Lasix to be administered daily for three days starting immediately, a chest x-ray, urinalysis, and duoneb nebulizer treatments four times daily. The facility failed to implement the provider's orders as directed. The extra 20 mg of Lasix was not administered on the day it was ordered, and the duoneb nebulizer treatment was initially ordered three times daily instead of four. These orders were not correctly implemented until more than a week later. When questioned, the unit manager was unable to provide an explanation or documentation for the delay and incorrect implementation of the provider's orders.