Failure to Administer Medications and Assess Side Rail Use per Orders and Policy
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders, resident preferences, and accepted clinical standards for a resident with multiple complex medical diagnoses, including congestive heart failure, atrial fibrillation, and kidney failure. The resident had orders for several critical medications, including torsemide, amiodarone, lidocaine patch, and metoprolol, but these medications were not administered as ordered for an extended period. Documentation in the medication administration record (MAR) and progress notes repeatedly indicated that medications were on hold, waiting on prescription, or not available, with no evidence of timely follow-up with the pharmacy, physician, or hospice to resolve the issue. Additionally, there was no documentation of pharmacy contact, physician contact, or hospice notification regarding the missed or refused medications. The resident's care plan included interventions to administer medications as ordered and monitor for side effects and effectiveness, but these interventions were not consistently implemented. The MAR showed multiple days where medications were not given, and staff notes often lacked specific details about which medications were affected. The facility's own policies required timely ordering and administration of medications, as well as clear documentation and communication with the pharmacy and prescribers, but these procedures were not followed. The facility also failed to utilize available emergency medication kits (E-Kits) to obtain necessary medications, despite having relevant drugs in stock. In addition to medication administration failures, the facility did not assess or document the use of side rails for the resident, despite their use following a fall. The facility's policy required a side rail assessment, documentation of rationale, and consideration of less restrictive alternatives, but there was no evidence of such assessment or documentation in the resident's record. The resident was found on the floor after a fall and later found in another resident's room, having climbed over side rails, yet there was no order or care plan documentation regarding side rail use. Interviews with staff revealed inconsistent recollections about the resident's cognitive status and the events surrounding the use of side rails.