Failure to Follow Physician's Orders for Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure that physician's orders were followed for three residents, as evidenced by missing documentation and administration of prescribed medications and treatments. For one resident with multiple complex diagnoses, including diabetes and end stage renal disease, there was no documentation of daily weights on several specified dates as ordered, and insulin administration was not recorded on certain days. Additionally, blood sugar checks were not documented as ordered on two occasions. For another resident with Alzheimer's and other chronic conditions, there was no documented evidence that prescribed medications for anxiety, hypertension, and heart disease were administered on multiple dates. A third resident with heart disease and hypothyroidism did not have documented administration of levothyroxine on several dates. The DON confirmed during interview that there was no documented evidence these residents received their medications or treatments as ordered on the specified dates. Facility policy requires medications to be administered as ordered, with documentation on the MAR and timely physician notification of omissions. The lack of documentation and administration of ordered medications and treatments for these residents constituted a failure to follow physician's orders.