Failure to Follow Physician Orders for Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure that weights were obtained and medications were administered in accordance with physician orders for five residents reviewed for nursing services. For one resident with adrenocortical insufficiency, two doses of prescribed prednisone were not administered as ordered, and there was no documentation of a rationale or provider order for withholding the medication. The DON confirmed the missed doses and lack of documentation. For three residents with congestive heart failure and hypertension, medications such as metoprolol and digoxin were administered without obtaining required pre-administration assessments, including blood pressure and heart rate, as specified in the physician orders. Documentation showed that these assessments were either not performed or not recorded prior to medication administration, and there was no documentation explaining the rationale for administering the medications without the required assessments. Additionally, for one resident with congestive heart failure, daily weights were not consistently obtained as ordered, and significant weight gains that should have triggered provider notification were not acted upon or documented. The DON confirmed that weights were not consistently documented or reported as required by the provider orders.