Medication and Treatment Delays in LTC Facility
Penalty
Summary
The facility failed to ensure timely and appropriate quality of care for three residents, as evidenced by issues with medication administration and treatment orders. Resident #24 experienced delays in receiving prescribed medications, including Lumigan and other medications, due to staff awaiting delivery. Despite the medications being delivered, they were not administered timely, resulting in missed doses. The Unit Manager was unable to provide a reason for the delay in administration, and some medications that were available in the emergency stock were not utilized. Resident #102 did not receive treatment as per physician orders for a self-inflicted skin area on the right lateral lower leg. Observations revealed the area was uncovered and had bloody drainage, with staff unsure about the treatment status. The resident complained of itching from the gauze, and staff did not follow the prescribed treatment plan, opting instead to apply lotion without a physician's order. This inconsistency in care was confirmed through interviews with staff, who acknowledged the resident's tendency to scratch the area. Resident #517 had a skin tear on the left leg that was not documented with a physician's order for care. Observations showed the area was covered with a dressing, but there was no order for the treatment. Staff interviews revealed a lack of clarity on who applied the dressing, and the Unit Manager confirmed the absence of a physician order for the care of the skin tear. This oversight in documentation and treatment planning highlights a gap in the facility's adherence to professional standards of practice.
Plan Of Correction
Resident #24 completed her on on and per the podiatrist she had no signs of. Per the orthopedic surgeon on the residents healed and there were no concerns documented. The resident received her as ordered on and discharged from the center on. Resident #102 will have his care completed per the physician orders. The for resident #517 has resolved. Resident #517 will have his care completed per physician orders. Residents with and orders were audited on to ensure that their or were administered per physician orders. No other residents were affected by this alleged deficient practice. Residents with will have their care completed per physician orders. Care orders were audited on to ensure no other residents were affected by this alleged deficient practice. Licensed nurses will be educated on following physician orders for care, and by the Director of Education/designee. Licensed nurses will be educated to obtain a care order prior to providing a treatment by the Director of Education/designee. Orders will be audited for administration per physician orders weekly x4 weeks and monthly x12 months by the preventionist/designee. Orders will be audited for administration per physician orders weekly x4 weeks and monthly x12 months by the DCS/designee. Care treatments will be audited for accuracy weekly x4 weeks and months x12 months by the DCS/designee. All audits will be brought to QAPI monthly for review.