Failure to Follow Physician Orders and Document Medication Parameters
Penalty
Summary
The facility failed to consistently follow professional standards of clinical practice by not adhering to physician orders for medication administration and by not clarifying ambiguous orders for two residents. In the first instance, a resident with Alzheimer's disease, diabetes mellitus, and a stage 4 sacral pressure ulcer had a physician's order for tramadol to be administered before wound care. However, documentation showed that the pain medication was only given once daily in the morning, while wound treatments were performed during the evening and night shifts, contrary to the physician's order. The LPN assigned to the resident's care confirmed that the order should have been clarified since the wound care was not performed on the day shift, and the medication was not administered as intended prior to the wound treatment. In the second instance, another resident with heart failure, hypertension, and benign prostatic hyperplasia had a physician's order for finasteride with specific parameters to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 60. Review of the medication administration records over several months revealed that nurses documented administration of the medication but did not record the required blood pressure and heart rate at the time of administration. Interviews with nursing staff and management confirmed that it was expected for nurses to check and document these vital signs per the physician's order, but this was not consistently done. The lack of documentation meant there was no evidence that the medication was administered in accordance with the specified parameters. Both deficiencies were confirmed through interviews with nursing staff and review of facility policies, which require medications to be administered as ordered by the physician and for vital signs to be recorded when medications have specific parameters. The facility's own policies also state that medications must be given in accordance with orders, including any required time frames, and that vital signs should be documented on the medication administration record when applicable.