Failure to Clarify Medication Orders and Provide Scheduled Therapy
Penalty
Summary
The facility failed to ensure professional standards of care were followed for three residents reviewed for quality of care. For one resident with mild cognitive impairment, dysphagia, sepsis, and Parkinson's disease, there was a lack of clarification regarding the frequency of Carbidopa/Levodopa ODT dosing after the resident's spouse brought in medication and requested a change due to swallowing difficulties. Documentation showed conflicting orders and a possible transcription error, but there was no evidence that the provider clarified the correct dosing frequency. For another resident with chronic lymphocytic leukemia, the medication order for Voriconazole was unclear and inconsistent with the hospital discharge summary, and the DON acknowledged the order should have been clarified with the physician. A third resident, admitted for aftercare following digestive surgery and heart failure, did not receive scheduled physical and occupational therapy sessions as ordered. Progress notes lacked documentation on the number of therapy attempts, whether the resident refused therapy, or reasons for missed sessions. There was also no evidence that missed therapy sessions were made up on the weekend, and a progress note explaining a missed session was entered 14 days after the fact. These deficiencies demonstrate failures in medication order clarification and therapy service delivery according to professional standards and resident care plans.