Multiple Failures in Medication Administration, Oxygen Therapy, and Infection Control
Penalty
Summary
The facility failed to maintain professional standards of quality for multiple residents in several key areas. One resident was found with a medication left unattended on her bedside table without a completed self-administration assessment and without nursing staff present. The medication, intended for blood pressure management, was not administered at the scheduled time, and the nurse responsible left the medication while retrieving an item and did not return. Both the Assistant Director of Nursing and the Director of Nursing confirmed that this was a medication error and a violation of facility policy, as medications should not be left unattended and self-administration assessments are required. Another resident receiving oxygen therapy had an incomplete physician order that did not specify the oxygen flow rate. The respiratory therapist and nursing staff acknowledged that the order should have included the specific rate to ensure proper administration. Additionally, a resident receiving continuous oxygen therapy did not have the required 'Oxygen in Use/No Smoking' signage posted inside or outside the room, as mandated by facility policy. Staff interviews confirmed that the absence of signage was a failure to follow established procedures and could have led to unsafe conditions. Further deficiencies included improper insulin pen administration by a licensed nurse for two residents, where the insulin pen tip was not disinfected with an alcohol wipe before and after use, contrary to facility policy and infection control standards. Another resident's nebulizer tubing was found unlabeled, unprotected, and touching the floor, with staff confirming that tubing should be labeled, changed weekly, and stored in a privacy bag. Lastly, a resident with an open wound did not have a physician order for enhanced barrier precautions upon admission, despite facility policy requiring such precautions for residents with wounds. Staff interviews indicated that the omission was due to a lapse in the admission assessment and order process.