Failure to Follow Medication and NPO Orders for Two Residents
Penalty
Summary
The facility failed to provide treatment and care in accordance with standards of care for two residents. One resident had a diagnosis that included secondary malignant neoplasm of the lung and was ordered to receive 4 mg of decadron the day before, the day of, and the day after a scheduled cancer infusion. The Medication Administration Record showed that decadron was administered on February 24, 2026, in preparation for an infusion appointment at a cancer center on February 25, 2026. However, the resident did not attend the infusion appointment because transportation had not been arranged, and the appointment had to be rescheduled. A subsequent progress note documented that the CRNP ordered discontinuation of the three days of decadron since the infusion was not given. Another resident had an order to remain NPO after midnight prior to a scheduled cataract surgery. Nursing had sent a Diet Order and Communication slip to the kitchen indicating that this resident was not to receive a breakfast tray on the morning of the scheduled surgery. Despite this written communication and the active NPO order, the resident received a breakfast tray from the kitchen and ate breakfast, resulting in the cancellation of the cataract surgery appointment. The DON confirmed that the resident received a breakfast tray while the NPO order was in place.
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