Failure to Follow Physician Orders for New Medication After Outside Appointment
Penalty
Summary
The facility failed to provide services in accordance with professional standards of quality for one resident when staff did not follow physician orders for a new medication. After returning from a neurology appointment, the resident, who had moderately impaired cognition and diagnoses including Wernicke's encephalopathy, muscle wasting, diabetes, and vascular diseases, was prescribed gabapentin 100 mg daily to treat nerve pain. The after-visit summary from the neurologist included this new medication order. However, the facility did not implement the physician's order for gabapentin for 10 days following the resident's return. The medication was not added to the resident's medication list, and staff did not follow up to obtain the necessary paperwork or clarify the order with the physician's office. The omission was only discovered when a family member inquired about the medication, prompting staff to contact the physician and obtain the order for gabapentin.