Neglect in Medication Management and Lab Follow-Up
Penalty
Summary
The facility failed to protect residents' rights to be free from neglect, specifically in the area of medication management and follow-up laboratory orders for medication therapeutic levels. Eleven residents were affected, with serious harm occurring to one resident whose medication levels were not monitored, and consultation was not obtained as requested by the provider. This resident experienced a significant medical event and had to be transferred to a higher level of care due to the facility's failure to monitor and manage medication levels appropriately. The report details multiple instances where residents' medication levels were not checked as ordered, and abnormal lab results were not communicated to the appropriate medical providers. For example, one resident had low medication levels that were not reported to the physician, leading to a severe medical event. The facility's process for managing lab orders and results was inadequate, with orders not being transcribed correctly, and lab results not being reviewed or acted upon in a timely manner. Interviews with staff, including the DON and medical providers, revealed systemic failures in the facility's processes for lab management and physician notification. The DON admitted to not having a primary person assigned to oversee labs and review results, leading to missed lab draws and unreported critical lab values. The facility's lack of a structured process for ensuring lab orders were executed and results communicated contributed to the neglect of residents' medical needs.
Plan Of Correction
Free from & Neglect/N204 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practices? Residents #5 and #10 no longer reside in the facility. Laboratory orders for medication management were received for residents #1, #2, #3, #4, #6, #7, #8, #9, and #11. Results of labs were reported to resident physicians, documented in the clinical record, and new orders were transcribed as indicated. Consult was for resident #1 as requested by physician. 2. How you will identify other residents who have the potential to be affected by the same deficient practice and what corrective actions will be taken. A facility-wide audit of current residents on medications was conducted by Director of Nursing/designee to ensure that residents on medications had appropriate lab monitoring orders in place and that consultation orders for were completed as indicated. Any residents identified without lab monitoring orders or fully executed consults were reported to physician and new orders transcribed as indicated. 3. What measures will be put in place or what systematic changes you will make to ensure that the deficient practice does not recur. Director of Nursing/Designee will educate licensed nursing staff on the lab monitoring process to include ensuring that residents on medication receive proper lab monitoring, physician notification of abnormal lab values or refused labs, documentation of physician notification and new orders is recorded in the resident clinical record, and consultation orders for are properly executed. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur. What quality assurance program will be put into place. Director of Nursing/Designee will randomly audit residents on medications to ensure that appropriate lab orders for monitoring medication levels are in place weekly for four weeks and then monthly for two months. Results of the audits will be submitted by the Director of Nursing/designee to the Quality Assessment, Assurance, and Compliance Committee monthly for three months for further recommendations and guidance.
Removal Plan
- The Regional Nurse Consultant educated the Administrator and Director of Nursing on neglect, and as they relate to ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, physician notification of abnormal labs, and follow-up procedures and resident condition change related to laboratory results. Education is 100% complete.
- The Consultant Physician provided education to facility Medical Director and physician extender on neglect, and as they relate to ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, and follow-up procedures related to laboratory results.
- The Director of Nursing or designee educated 100% of staff on neglect, and as they relate to ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, physician notification of abnormal lab values, and follow-up procedures related to laboratory results.
- Process Change: Director of Nursing is responsible for reviewing consultation log(s) and making sure that consultation orders were executed, monitoring the laboratory monitoring processes for medications that require lab levels, reviewing progress notes to ensure physician notification has taken place, and ensuring complete follow-through with relation to laboratory results.
- All education and in-service sign-in sheets were reviewed and validated 53 out of 93 employees had received neglect, and training as they relate to ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, physician notification of abnormal labs, and follow-up procedures and resident condition change related to laboratory results.
- Interviews were conducted with 53 staff members across various shifts, the Nursing Home Administrator, the Assistant Director of Nursing, the DON, and the Medical Director. The staff members were able to verbalize they had been trained and were knowledgeable about the new policies.