Failure to Administer Medications and Ensure Adequate Oxygen Supply During Appointments
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with multiple complex medical conditions, including COPD, systemic lupus erythematosus, legal blindness, schizophrenia, epilepsy, and a contracture of the left hand. The resident was admitted and readmitted with orders for daily topical skin treatment, scheduled inhaled medications for COPD, and continuous oxygen therapy. Documentation review revealed that on several occasions, there were no staff initials or records indicating that the resident received prescribed medications and treatments, such as Aquaphor ointment, Symbicort inhaler, and Albuterol nebulization, as ordered by the physician. Interviews with nursing staff confirmed the lack of documentation and administration for these treatments on specific dates. Additionally, the facility failed to ensure the resident had an adequate supply of oxygen during off-site clinic appointments. The resident, who required continuous oxygen at 4-5L/min via nasal cannula, reported that only one oxygen tank was provided for clinic visits, which was insufficient to last the duration of the appointments. Observations and interviews with staff and the oxygen provider confirmed that the type of tank supplied would only last approximately two hours at the prescribed flow rate, and that the facility did not have a policy or plan to ensure residents had enough oxygen for transportation and appointments outside the facility. The Director of Nursing acknowledged that the facility did not administer medications and treatments as ordered and did not have a policy addressing oxygen provision during transportation. The resident experienced shortness of breath during clinic appointments due to the insufficient oxygen supply, and had to switch to a second tank when the first ran out. The facility's own policies required medications and treatments to be administered and documented as prescribed, but these were not followed in this case.