Failure to Clarify NPO Medication Orders and Provide Timely Respiratory Equipment
Penalty
Summary
The facility failed to ensure continuity of care by not seeking clarification from physicians regarding oral medication orders for residents who were designated as NPO (nothing by mouth), and by failing to obtain necessary respiratory equipment for a newly admitted resident. For multiple residents, there were active NPO orders in place, yet the Medication Administration Records showed that oral medications were documented as administered during the NPO period. In some cases, the Director of Nursing (DON) stated that medications were given via tube, but the orders and documentation did not reflect this clarification, nor was there evidence of provider or pharmacy consultation as required by facility policy. Additionally, the facility did not conduct monthly reviews of orders by nursing staff, leaving them for physician signature without further verification. A newly admitted resident with a hospital order to continue home CPAP therapy for obstructive sleep apnea did not receive the required respiratory equipment upon arrival. The DON was uncertain if the CPAP order was included in the admission orders, and the equipment was not available until the following day. The resident was discharged back to the hospital before physician orders, diagnosis list, and care plan were initiated. These failures were confirmed through record review, staff interviews, and resident interviews, and were found to have the potential to affect a limited number of residents.