Failure to Notify Physician of Change in Condition and Omission of Prescribed IV Antibiotics
Penalty
Summary
The facility failed to adhere to professional standards of care by not providing immediate physician notification for a resident who experienced a significant change in condition, and by not administering prescribed medications as ordered for two other residents. Specifically, one resident with diagnoses including pneumonia, COPD, acute respiratory failure with hypoxia, and severe protein-calorie malnutrition exhibited low oxygen saturation levels (as low as 55% and 77% after oxygen was reapplied), confusion, and refusal of medications and meals. Despite these changes, there was no documented evidence that the physician was notified of the resident's deteriorating condition, as confirmed by the Nursing Home Administrator. Additionally, two residents did not receive their prescribed intravenous antibiotics according to physician orders. One resident with end stage renal disease, dialysis dependence, a history of falls, and diabetes mellitus type 2 did not receive a scheduled dose of Cefepime IV antibiotic for infection. Another resident with a history of subarachnoid hemorrhage, seizures, a stage 4 sacral pressure ulcer, and osteomyelitis did not receive Daptomycin IV antibiotic as ordered on three consecutive days. The Director of Nursing confirmed that the clinical records lacked evidence of administration of these medications as prescribed.