Failure to Follow Hospital Discharge Orders and Dietary Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality by not following hospital discharge orders and dietary recommendations for one resident. The resident was cognitively impaired, required extensive assistance with care, was incontinent, received insulin, and had multiple diagnoses including ESBL UTI, bacteremia, diabetes, hypertension, atrial fibrillation, orthostatic hypotension, and Alzheimer’s dementia. Discharge instructions from the Veterans Affairs Medical Center directed continuation of Insulin Aspart per sliding scale before meals and at bedtime, Metoprolol Succinate 12.5 mg daily with specific hold parameters, Levofloxacin 750 mg every 48 hours with the final dose due on a specified date to complete a one-week course, and a consistent carbohydrate diet. Physician’s orders on admission and subsequent days did not consistently reflect these discharge instructions. Initial insulin orders included Insulin Aspart per sliding scale before breakfast and at bedtime, plus fixed one-unit doses before lunch and dinner, which were then discontinued the next day because they did not match the hospital discharge orders. After this discontinuation, there was no documented evidence on the MAR that the resident’s blood sugars were monitored for several days until a new order for Insulin Lispro per sliding scale was written. For Metoprolol, the resident was initially ordered Metoprolol Tartrate 12.5 mg daily with hold parameters, and later, after a cardiology visit, Metoprolol Succinate ER 12.5 mg daily with the same hold parameters was ordered; however, the clinical record contained no documentation that blood pressure and heart rate were checked as ordered prior to administration. The facility also did not follow the antibiotic and diet instructions as specified. The discharge instructions required Levofloxacin 750 mg every 48 hours with the last dose due on a specific later date, but the physician’s order at the facility directed only a single 750 mg dose, which was administered earlier than the hospital’s indicated final dose date, and there was no evidence that the last scheduled dose per discharge instructions was given. Regarding diet, the hospital discharge instructions called for a consistent carbohydrate diet, but the physician’s orders and dietary documentation showed the resident was placed on a cardiac/heart healthy diet instead. The dietitian later recommended changing to a consistent carbohydrate diet and adding Glucerna supplements, and subsequent notes documented ongoing recommendations and physician agreement to liberalize the diet; however, the resident’s diet order remained cardiac/heart healthy until it was finally changed to a consistent carbohydrate diet at a later date. The DON confirmed that the insulin, metoprolol, levofloxacin, and diet were not ordered per hospital discharge instructions, that ordered BP and HR checks prior to metoprolol administration were not documented, and that the diet was not changed as recommended by the dietitian.
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