Neglect in Medication Management and Lab Follow-Up
Penalty
Summary
The facility failed to protect the residents' right to be free from neglect, particularly 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. The report details multiple instances where residents' medication levels were not properly monitored, and laboratory results were not communicated to the appropriate medical personnel. For example, one resident's medication levels were consistently low, yet there was no evidence that the physician was notified of these results. Additionally, there were lapses in ensuring that lab orders were entered into the lab portal, leading to missed or delayed lab draws. The Director of Nursing acknowledged a system failure in the facility's lab process, which contributed to these deficiencies. Interviews with staff revealed a lack of clear responsibility for overseeing lab orders and results. The facility's process for managing lab work was described as broken, with no designated person to ensure that lab results were reviewed and communicated to providers. This systemic issue resulted in residents not receiving the necessary medical oversight, leading to potential harm and inadequate care.
Plan Of Correction
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 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' 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. 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.