Failure to Monitor and Assess Medication Administration
Penalty
Summary
The facility failed to provide adequate monitoring and assessment for a resident, leading to a deficiency in quality of care. Specifically, the facility did not adhere to its own medication administration policy, which requires vital signs to be checked and verified before administering medications. For Resident #1, there was a failure to assess the accuracy of medication administration, as evidenced by the administration of a medication without verifying the resident's vital signs as per the prescriber's orders. The orders required that the medication be held if certain vital sign thresholds were not met, but the facility did not document the necessary vital sign checks before administering the medication. Additionally, the facility did not comply with the doctor's orders to obtain and document vital signs every shift for 72 hours, followed by a reassessment for continued monitoring. There were significant gaps in the documentation of vital signs, with no recorded measurements between certain times, indicating a lack of reassessment and monitoring as required. Interviews with staff revealed a lack of consistent understanding and execution of procedures for managing changes in a resident's condition, further contributing to the deficiency.
Plan Of Correction
How the corrective action will be accomplished for any resident affected by deficient practice: Resident #1 has been discharged from the facility. LPN D and LPN B and licensed nursing staff involved with Resident #1 care were educated regarding Medication Administration, following medication administration parameters, identifying any change in residents vital signs from baseline and it in timely manner, and identifying change conditions and notifying physicians with residents change of conditions. How we identified other residents/areas that could potentially be affected and what corrective action will be taken: All residents on medications have potential to be by this practice. An audit of all current residents with medications with parameters including was completed to ensure medications are administered in accordance with the prescribers orders and parameters are followed through as per MD order. Any findings were addressed accordingly. Measures put in place or systemic changes made to ensure that the deficient practice will not recur: The facility's Medication Administration policy was reviewed by DON and no revision was required. Licensed Nursing staff were educated regarding Medication Administration, following medication administration parameters, identifying any change in residents vital signs from baseline and it in timely manner, and identifying change conditions and notifying physicians with residents change of conditions to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Medication administration competency on following parameters will be conducted with the license nurses. Unit Managers/Supervisors will monitor clinical alerts including, vital signs during the morning meeting and the end of each shift and any abnormality will be reported to MD for immediate interventions. How the corrective actions will be monitored and what quality assurance will be put in place title of person responsible for monitoring: The DON/Designee will audit randomly 10 residents on medications with parameters including weekly x4 then monthly x 3 to ensure that the parameters as ordered is being followed and MD notify as indicated. The results of all audits will be reported to QAPI committee for review and feedback on a monthly basis for the duration of audit until compliance achieved. Responsible party: DON