F0684

D

Failure to Follow Physician Orders for Medications, Tube Feeding, and Wound Care

Reading, Pennsylvania Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement physician orders for two residents. For one resident with Parkinson’s disease, aphasia, a history of stroke, and an abdominal feeding tube for nutrition and medications, clinical record review showed multiple ordered medications were not documented as given on a specific date. The MAR for that date lacked documentation of administration of amlodipine besylate ordered daily for hypertension at 2:00 p.m., carbidopa-levodopa ordered three times daily for Parkinson’s disease at 12:00 p.m., and baclofen ordered three times daily for muscle spasms at 12:00 p.m. In addition, physician orders directing continuous tube feeding with Jevity 1.5 at 65 mL/hr from 1:00 p.m. to 7:00 a.m., and specific water flushes (60 mL before and after each medication and feeding, 5 mL between medications, and every shift) were not documented as completed on the day shift for that date. The TAR showed no evidence that the tube feeding formula was administered as ordered or that the required tube flushes were performed on that shift.

For another resident with dementia and depression, a physician’s order directed daily day-shift wound care to the right hand’s second and third fingers, including cleansing with saline, application of oil emulsion gauze, and wrapping with a gauze dressing. Review of the TAR for a specific date showed no documented evidence that this wound treatment was provided. Observations on a later date revealed that the resident’s affected fingers were covered with band aids instead of the ordered gauze dressing. In an interview, the DON confirmed there was no evidence that staff implemented the physician’s orders as written and that the resident’s hand wounds were covered with band aids rather than the prescribed gauze dressing.