Deficiencies in Medication Administration and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care for several residents, as evidenced by multiple deficiencies in medication administration and monitoring. Resident R17, who was diagnosed with depression, anxiety, and bipolar disorder, did not receive the prescribed Doxepin medication for an extended period due to pharmacy delivery issues. This resulted in 13 missed doses in November and two missed doses in December, which was confirmed by the Assistant Director of Nursing. Resident R45, diagnosed with high blood pressure, diabetes, and adult failure to thrive, experienced several instances of abnormal blood glucose levels that were not reported to the physician. Additionally, a Licensed Practical Nurse held a dose of Lantus insulin without a physician's order, which was confirmed by the Director of Nursing. Similarly, Resident R47, who has diabetes, had multiple high blood glucose readings that were not communicated to the physician, as confirmed by the Director of Nursing. Furthermore, the facility failed to schedule necessary medical appointments for Residents R50 and R53. Resident R50, who has a seizure disorder, did not have a neurology appointment scheduled as ordered by the physician. Resident R53, diagnosed with high blood pressure, diabetes, and dementia, did not have a scheduled colonoscopy as per physician orders. These failures were confirmed by a clerk who admitted to not scheduling the appointments.
Plan Of Correction
Meeting held with pharmacy to discuss process when medications are not delivered. Re-training provided to NHA, ADON, and Unit Manager, and additional pharmacy system access provided. Meeting held with MD and NP by NHA regarding streamlining process. Modifications made to morning clinical meeting. Discussion held with NP regarding R17 regarding any changes and R45 and R47 regarding blood glucose measurements. Charts were reviewed retroactively for R17, R45, and R47. An audit was completed on like residents on 1/9/2025 to ensure there were no additional medication issues and notification to physicians were occurring timely for missed medications and blood sugar issues. Parameters were implemented retroactively for blood sugars. An appointment was immediately made for a neurology appointment with an alternative physician for R50. An appointment was immediately made for a colonoscopy for R53. Education was provided to the RNAC, ADON, unit manager, and RN supervisors by the DON or designee on notification to physicians, hypoglycemia management, medication administration, blood glucose monitoring, and resident rights, and prompt appointments for outside consults on or before 2/11/2025. Audits will be completed by the DON or designee on prompt appropriate treatment and care during AM clinical 3 times a week x four weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.