Failure to Implement Physician-Ordered Medication Change
Penalty
Summary
Staff failed to ensure a resident received necessary care and services in accordance with physician orders when they did not obtain and implement a nephrologist's order to increase Lasix. After a nephrology appointment, the nephrologist ordered an increase in Lasix to 40 mg twice daily, and the resident's family provided the consultation paperwork to facility staff. However, the order was not entered or implemented until seventeen days later. During this period, the resident experienced worsening leg swelling and weakness, and therapy was discontinued. The consultation paperwork was not found in the resident's record, and staff did not follow up to obtain the missing orders from the provider. Interviews with the DON, medical records staff, and unit manager confirmed that the process for handling consultation forms was not followed, and no follow-up occurred when the form was missing. The resident, who had chronic obstructive pulmonary disease, pulmonary hypertension, diastolic heart failure, and chronic kidney disease, was severely cognitively impaired at the time. The resident ultimately required hospital transfer due to increased edema and fever, and was admitted with edema and a urinary tract infection.