Failure to Follow Physician Orders for Medications, Wound Care, and Accuchecks
Penalty
Summary
Surveyors identified that the facility failed to follow physician's orders and provide appropriate treatment and care according to orders, resident preferences, and goals for multiple residents. Specifically, several residents did not receive their medications at the prescribed times, with documented instances of medications being administered hours after the scheduled times. Residents reported that their medications were sometimes late or, in some cases, not given at all. Review of medication administration records over a 30-day period confirmed repeated late administration of critical medications, including anticoagulants, antihypertensives, and psychotropic drugs. In addition to medication administration issues, the facility did not complete ordered wound care treatments for a resident with multiple venous ulcers and moisture-associated skin damage. The prescribed wound care regimen, which included cleansing, application of topical medications, and specific dressing changes, was not performed as ordered on a documented date. The administrator confirmed that these treatments were missed. The facility also failed to perform blood glucose monitoring (accuchecks) as ordered for several residents with diabetes. Multiple instances were found where daily, twice daily, or scheduled accuchecks were not completed according to physician orders. The DON confirmed that these orders were not followed, and the missed accuchecks were verified through record review.