Failure to Reconcile Medications and Follow Physician Orders Resulting in Resident Harm
Penalty
Summary
The facility failed to protect residents from neglect by not accurately reconciling medications, failing to follow up on physician orders for laboratory testing, medical equipment, and outpatient services, and not administering medications as ordered. One resident was readmitted from the hospital with a history of seizures and a G-tube, requiring a specific dose and form of seizure medication. The facility did not accurately reconcile the hospital discharge medication orders, resulting in the resident receiving an incorrect dose and form of medication. Despite multiple notifications to the physician and pharmacy about the need to change the medication to a solution for G-tube administration, the correct order was not implemented in a timely manner. The resident subsequently experienced multiple seizures, a fall with head trauma, and ultimately died from his injuries. Laboratory orders for seizure medication levels were not completed as ordered, and follow-up on outpatient cardiology appointments and equipment was not performed. Another resident with epilepsy and a feeding tube was readmitted to the facility, but the hospital discharge medication list was not properly reconciled. Several medications, including a seizure medication, were omitted from the facility's orders, and the resident did not receive these medications. The resident experienced seizure-like activity and required transfer to a higher level of care. Staff interviews revealed that the admitting nurse did not verify the medication list with the physician, and the correct discharge medication list was not obtained until after the incident. The facility initiated an investigation after being notified by the resident's family that the resident had not received her seizure medications since her last hospitalization. A third resident with diabetes and epilepsy was not managed according to physician orders for blood sugar testing and insulin administration. An LPN administered large doses of insulin without a physician's order after observing high blood sugar readings, and failed to document the blood sugar readings or notify the physician as required. The resident was subsequently sent to the hospital for hyperglycemia and influenza A. Staff interviews confirmed that the nurse did not follow the prescribed sliding scale insulin orders and acted without proper authorization or documentation.