F0658

D

Failure to Follow Physician Orders for Cardiac Medication and Hand Splint Use

Socorro, New Mexico Survey Completed on 12-16-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders and professional standards of practice for two residents. For one resident with significant cardiac conditions, including diastolic congestive heart failure, chronic atrial fibrillation, a pacemaker, and cardiomyopathy, the physician ordered amiodarone 200 mg once daily with instructions to hold the medication if the systolic blood pressure was less than 100, diastolic blood pressure less than 50, or pulse less than 60. Review of the medication administration records for April, May, and June 2025 showed that amiodarone was documented as given every morning, but there was no documentation of blood pressure readings on the MAR. Blood pressure summaries for those months showed that blood pressure was recorded only a few times (4–5 times per month) despite daily administration of the medication. The DON and the Regional Clinical Nurse both stated that the expectation was that the resident’s blood pressure should be taken and documented before administering amiodarone and confirmed that staff were not documenting that this was done.

The deficiency also involves a second resident with a diagnosis of a left hand contracture. A physician order dated 10/08/25 directed that the resident wear a left modified palm guard splint daily or as tolerated. During an observation of the secured unit, the resident was not wearing the splint. One CNA reported she did not know the resident was supposed to wear a splint, and another CNA stated she had been told about the splint the previous day, recalled seeing the resident wear it in the past, but had not seen the splint or the resident wearing it for a long time and did not know where the splint was. The DON stated she did not know about the splint order and reported that the order had been discontinued the day before because the resident was not compliant with wearing the brace.

Further record review for the second resident showed that the care plan dated 10/27/25 contained no documentation that the resident was non-compliant with wearing the splint. The Director of Rehabilitation stated that the splint had been ordered by an occupational therapist, confirmed the order for daily or as-tolerated wear, and reported that the order was discontinued without consultation with the occupational therapist, which she stated should have occurred. The Regional Clinical Nurse confirmed that the splint order was discontinued on 12/10/25 and stated that hospice discontinued the order and that the occupational therapist should have been consulted prior to discontinuation. These findings demonstrate that staff did not follow or appropriately manage physician and therapy orders for the resident’s splint.