Failure to Follow Physician Medication and Monitoring Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure physician orders were followed as written for one resident. The resident was admitted with multiple diagnoses, including atrial fibrillation, psoas muscle abscess, heart failure, chronic gout, bacteremia, osteomyelitis of the lumbar vertebra, neoplasm of uncertain behavior of cerebral meninges, type 2 diabetes, a non-pressure chronic ulcer of the right foot with fat layer exposed, and hypertension, and was documented as cognitively intact. Hospital discharge orders dated 12/05/25 included ergocalciferol 50,000 units by mouth weekly. However, when the orders were transcribed into the facility’s physician orders on 12/05/25, ergocalciferol was entered as 5,000 units by mouth weekly on Monday for vitamin D deficiency, resulting in a discrepancy from the hospital discharge paperwork. Further review of the physician orders and MAR for December 2025 showed additional failures to follow ordered treatments. Daily weights ordered to be taken first thing in the morning, with instructions to notify the physician if weight increased three pounds in 24 hours or five pounds in one week, were not obtained on multiple dates throughout the month. Cyclobenzaprine 5 mg twice daily, ordered as a muscle relaxant until 12/15/25, was not administered on the evening of 12/05/25, and gabapentin 400 mg by mouth four times daily was not signed off as administered on the evening of 12/05/25. During interview, the Administrator confirmed that daily weights were not obtained on the identified dates, that the ergocalciferol order had been transcribed incorrectly and the resident received three doses weekly since admission, and that cyclobenzaprine and gabapentin were not signed off for the evening shift on 12/05/25. The facility’s medication administration policy requires medications to be administered as ordered by the physician and documented on the MAR after administration.
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