Failure to Follow Treatment Orders, Hypoglycemia Protocol, and Medication Parameters
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders and facility policy for several residents. For one resident with dementia, stroke history, and ADL self-care deficits, physician orders required the use of geri-sleeves on arms and legs to prevent skin tears and, after an incident in which the resident struck her arm on a bed rail and sustained two skin tears and an abrasion, daily wound care with normal saline, Xeroform, dry gauze, and kerlix until healed. Although incident and wound care notes documented the new skin condition and that wound care was to complete the treatment, the treatment administration record showed the ordered arm treatment coded as “9 (see nurse’s notes)” on two days, indicating it was not completed by the nurse, and there was no wound assessment documented in the wound round section as required by facility policy. Another deficiency occurred when a resident with diabetes and congestive heart failure experienced hypoglycemia. An alert note documented that the resident was found clammy and not his normal self, oxygen was applied, and a blood sugar of 47 mg/dl was obtained, after which 911 was called and the resident was transferred to the hospital with a diagnosis of hypoglycemia. The record did not show that the physician was notified or that any hypoglycemia interventions, such as providing carbohydrates or administering glucagon, were attempted prior to transfer, despite the facility’s hypoglycemia protocol directing staff to give glucose if the resident is conscious and to contact the physician when blood sugar is below 60 unless specific call parameters exist. Additional deficiencies involved medication administration and holding medications without physician parameters. During a medication pass, an LPN withheld ordered metoprolol and amlodipine for a resident with chronic respiratory failure, diabetes, breast cancer, blindness, and congestive heart failure because the diastolic blood pressure was below 60, even though there were no physician-ordered blood pressure parameters to hold these medications. For another resident with hemiplegia after stroke, diabetes, and ischemic cardiomyopathy, the medication administration record showed multiple blank entries for scheduled Lantus insulin and Humalog sliding scale doses with no notes or orders explaining the omissions, and repeated held doses of Entresto and metoprolol without any physician orders or parameters authorizing these holds, despite care plans directing that insulin and cardiac medications be administered as ordered.
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