Failure to Follow Physician Orders for Medication and Tracheostomy Care
Penalty
Summary
Surveyors identified that the facility failed to follow professional standards of practice for medication and treatment administration for two residents. For one resident with muscle wasting, hypertension, and muscle disorders, a physician's order required Lyrica 150 mg to be administered every six hours for nerve pain. However, on a specific date, the medication was administered twice within one hour by two different nurses, as evidenced by the Medication Administration Record (MAR) and the Controlled Drug Declining Inventory Sheet. Both nurses confirmed in interviews that the physician's order was not followed regarding the timing and frequency of administration. For another resident with respiratory failure, malignant neoplasm of the supraglottis, dysphagia, and tracheostomy status, there was a physician's order for daily tracheostomy care, including cleansing the site with normal saline, patting dry, and covering with a drain sponge. Review of the MAR showed that from the first to the third of the month, there were no check marks or nurse initials to indicate that the tracheostomy care was performed as ordered. Staff confirmed that the absence of documentation meant the order was not followed.