Failure to Clarify Oral Medication Orders for NPO Resident
Penalty
Summary
The facility failed to ensure physician orders met professional standards of quality by not clarifying medication routes for a resident who was NPO and had swallowing difficulties. Record review showed that a resident readmitted with dysphagia, disease of the esophagus, and a gastrostomy had a nutritional care plan, revised 4/3/26, documenting the resident was NPO (nothing by mouth). Despite this, physician orders directed that prednisone 5 mg be given by mouth daily for renal insufficiency and magnesium glycinate 100 mg be given by mouth at bedtime for insomnia. According to the National Council of State Boards of Nursing, nurses are professionally obligated to clarify and verify any order that is incomplete, inaccurate, unclear, or contraindicated before implementing it. On 4/2/26 at 11:32 AM, the DON and CRN confirmed that the resident does not take anything by mouth and acknowledged that the provider’s orders should have been clarified prior to implementation. This failure created the potential for harm if the resident were to receive oral medications despite having difficulty swallowing.
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