Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to administer medications and treatments as ordered for multiple residents. One resident with a history of liver transplant and major depressive disorder did not receive several doses of their prescribed immunosuppressive medication, mycophenolate mofetil, on multiple occasions because the medication was unavailable. The resident, who was cognitively intact, expressed concern about missing these doses. The physician confirmed that missing scheduled doses of this medication was not good practice. Another resident with a history of stroke, major depressive disorder, and physical debility did not receive prescribed doses of aspart insulin on several occasions, with no documented reason or evidence that the medical provider was informed of the missed doses. The insulin order did not include parameters to hold the medication, yet it was not administered at times when blood sugar readings were recorded, and on other occasions, there was no documentation at all. Additionally, a resident with chronic respiratory failure and hemiplegia was observed during incontinent care requesting rectal cream for burning. The CNA applied Preparation H rectal cream, which was not within their scope of practice according to facility leadership. The resident's orders required staff to apply the cream and monitor vital signs, but the application was performed by a CNA rather than a licensed nurse. The DON confirmed that the CNA should not have been applying the rectal cream.