Failure to Administer Ordered Iron Transfusions
Penalty
Summary
The facility failed to ensure that a resident received iron transfusions as ordered, which was a deficiency identified during a review of facility policy, clinical records, and staff interviews. The resident, who was admitted with diagnoses of hereditary hemorrhagic telangiectasia and anemia, had a care plan indicating a risk for iron deficiency and required iron infusions on specific dates. However, the clinical record review on December 11, 2024, showed that the resident did not attend any of the scheduled appointments for the iron infusions. Interviews with staff revealed a breakdown in communication and scheduling. The Director of Transportation and the Unit Manager, a Registered Nurse, were involved in attempts to reschedule the appointments to a closer location, but there was a lack of follow-up and communication regarding the new appointment dates. The resident expressed frustration and aggression due to the missed appointments, and the Director of Nursing confirmed the facility's failure to provide the necessary treatment and care as ordered.
Plan Of Correction
Resident R1 was re-inserviced to not continue to set up their own appointments as this leads to potential delays in service as the facility is unaware of appointments residents make on their own. Resident R1 has been attending weekly appointments as ordered. Transportation services will audit the last 2 weeks of appointments to ensure resident appointments were scheduled for timely service and service was provided timely. The Administrator re-inserviced the director of transportation to ensure resident appointments were scheduled for timely service and service was provided timely. Transportation services will audit appointments for 2 weeks to ensure resident appointments were scheduled for timely service and service was provided timely. Audits will be shared with the QAPI committee to ensure continued compliance.