Medication Administration Failure in LTC Facility
Summary
The facility failed to ensure that all residents received the necessary care to maintain their highest practicable physical, mental, and psychosocial well-being, as evidenced by the experiences of two residents during an abbreviated survey. On a specific date, one resident reported to a Registered Nurse Supervisor that they requested pain medication at 7:30 PM but did not receive it. Another resident informed the same supervisor that they received some medication at 5:00 PM but did not receive their sleeping medication. In both cases, the narcotic logbook indicated that the medications were dispensed, but there was no documentation of administration on the electronic medication administration record. The facility's investigation revealed that the Licensed Practical Nurse responsible for administering the medications did not document the administration in the electronic medication administration record, despite the narcotic count being accurate. The investigation also identified other residents who did not receive their medications, suggesting a pattern of non-administration. The facility could not exclude the possibility of narcotic diversion, leading to the termination of the Licensed Practical Nurse involved. The residents involved had specific medical conditions that required careful medication management. One resident had diagnoses including hypertension, diabetes mellitus, hyponatremia, and malignant neoplasm, with a moderately impaired cognition score. The other resident had hypertension and a fracture, with intact cognition. Both residents had care plans that included interventions to anticipate their needs, which were not met due to the medication administration failures.
Penalty
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The facility failed to properly position residents during meals, affecting three individuals on the secured unit. Observations showed residents in tilt wheelchairs at inappropriate angles and one resident in a low wheelchair without leg rests, unable to reach their meal. Staff did not intervene to reposition the residents, and interviews confirmed the improper positioning. The facility's policy on dignity and respect was not followed.
Improper Positioning of Residents During Meals
Penalty
Summary
The facility failed to ensure proper positioning of residents during meals on the secured unit, affecting three residents. Observations revealed that two residents were seated in specialty tilt wheelchairs at angles between 60 to 75 degrees, with one resident's table height reaching their chin throughout the meal. The staff did not intervene or reposition the residents during the meal observation. Another resident was observed sitting in a low wheelchair without leg rests, with their feet dangling, and was not positioned properly at the table during breakfast. Despite staff presence, no intervention was made to reposition the resident to allow proper access to their meal. Interviews with staff confirmed the improper positioning of residents during meals. One staff member acknowledged that a resident was not positioned correctly at the table, citing concerns about the resident grabbing items off the table. The Director of Nursing verified that residents should be upright and properly positioned at an appropriate table height during meals. The facility's policy on Quality of Life - Dignity emphasizes care that promotes dignity, respect, and individuality, which was not adhered to in these instances.
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