Failure to Follow Physician Orders for Medication and PEG Tube Anchoring
Penalty
Summary
Facility staff failed to follow physician orders for three residents in a sample of eight, resulting in deficiencies related to medication administration and treatment implementation. For one resident, staff did not transcribe an order for antifungal medication (fluconazole) upon admission, despite the hospital discharge summary and medication list indicating it should be started immediately for a diagnosed candida urinary tract infection. The medication order was not entered until two days after admission, and the resident did not receive the prescribed medication during that period. Interviews with nursing staff confirmed that there was no reason for such a delay, as medications are typically available promptly through the facility's pharmacy and automated dispensing system. The Director of Nursing (DON) acknowledged that the medication should have been started on admission and confirmed the order was not present until two days later. For two other residents, staff failed to implement physician orders for the use of an anchor device to secure PEG (percutaneous endoscopic gastrostomy) feeding tubes. Observations revealed that neither resident had an anchor device in place, despite active physician orders specifying that the feeding tube should be anchored every shift. Treatment administration records indicated that staff had documented the presence of the anchor device each shift, but direct observation contradicted these records. Interviews with nursing staff revealed a lack of awareness regarding the physician orders for anchor devices, and staff reported using tape and gauze instead of the ordered device. The DON was not aware of the specific orders and stated that the facility did not use anchor devices for PEG tubes at the time of the survey. Facility policies regarding physician orders and enteral feeding tubes were reviewed. The policy on physician orders required that all medication and treatment orders be recorded upon admission, but the process was not followed in these cases. The enteral feeding tube policy did not address the use of anchor devices. The deficiencies were discussed with facility leadership, and no additional information or documentation was provided to explain the failures to follow physician orders.