Failure to Clarify Admission Orders and Timely Medication Administration
Penalty
Summary
Nursing staff failed to clarify admission orders, reconcile medications, provide timely medication administration, and coordinate with hospice and the physician for two residents following their readmission. For one resident with multiple complex diagnoses, including chronic hypoxic respiratory failure, severe malnutrition, and diabetes, there was no documentation of hospice admission paperwork or clarification of orders upon readmission. The resident was ordered NPO, but oral medications were still administered and documented, and there was no order or administration of enteral feeding for nearly 19 hours. The medical record lacked evidence of physician notification regarding the missed tube feeding, and the Director of Nursing (DON) was unaware of the lapse until it was pointed out during the survey. Additionally, the hospice nurse reportedly took the hospital discharge paperwork, and there was no documentation of communication with the physician or hospice to clarify orders or obtain missing information. For the same resident, progress notes indicated that the resident did not receive prescribed tube feeding upon return from the hospital, and the feed was only started the following morning after staff made calls to confirm orders. There was no documentation specifying who was contacted, what orders were clarified, or if the physician was notified about the missed feeding. The resident later became lethargic, experienced a significant drop in oxygen saturation, and had a critically high blood glucose level, leading to rehospitalization. The facility's admission policy required written physician orders for immediate care, including dietary instructions and medications, but these were not present or clarified at the time of admission. A second resident, readmitted with gastrointestinal diagnoses including esophageal ulcer and bleeding, did not receive scheduled gastrointestinal medication (Nexium) as ordered via PEG tube. The medication was not available in the facility's backup supply, resulting in missed doses until the evening after admission. The DON confirmed the importance of the medication given the resident's condition but stated that the medication was not administered until it was delivered the next day. The facility's backup medication list did not include Nexium, contributing to the delay in administration.