Failure to Administer Medications as Ordered and Implement Physician Recommendations
Penalty
Summary
Facility staff failed to follow physician orders for two residents, resulting in deficiencies related to medication administration and care coordination. For one resident with a history of glaucoma and multiple other diagnoses, an eye physician recommended the addition of Dorzolamide-Timolol eye drops to the resident's existing glaucoma treatment. The recommendation was made during an on-site consultation, but the report was sent to an outdated email address and was not received by current facility staff. As a result, the new medication order was not reviewed or implemented, and the resident did not receive the recommended eye drops for over 30 days. Interviews with staff revealed a lack of awareness regarding the new recommendation, and the facility's process for updating consultant contact information was not followed, leading to the oversight. In a separate incident, another resident was admitted with physician orders for an antibiotic to be administered four times daily. Upon review, it was found that the antibiotic was not initiated until the following day at noon, resulting in three missed doses. The delay was attributed to the late entry and verification of the medication orders in the electronic system, despite the medication being available in the facility's backup supply. The DON and Regional Director of Clinical Services were unable to clarify why certain doses were missed after the orders were entered into the system. Facility policies require that medications be administered according to prescriber orders and that consultation reports be reviewed and implemented as indicated. In both cases, failures in communication, documentation, and timely order entry led to residents not receiving prescribed treatments as ordered by their physicians.