Failure to Adhere to Medication Administration and Feeding Protocols
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted professional standards of clinical practice in several key areas. Licensed nurses did not administer medications in a timely manner to multiple residents, with medication administration times significantly delayed beyond the facility's policy of one hour before or after the scheduled time. For example, medications scheduled for early morning were not given until late morning or early afternoon for several residents with complex medical conditions, including Parkinson's disease, diabetes, heart failure, stroke, and hypertension. These delays were confirmed through review of medication administration records and direct interviews with staff, who acknowledged the late administration. Additionally, licensed nurses did not follow proper procedures for verifying resident identity or explaining medications prior to administration. Observations showed that nurses prepared and administered medications to several residents without checking identification or informing them about the medications being given. When questioned, the nurses admitted to omitting these steps. Facility policy requires verification of resident identity and explanation of medications, but these procedures were not followed during the observed medication passes. The facility also failed to follow physician orders for continuous gastrostomy feeding for a resident dependent on tube feeding. Observations revealed that the resident's feeding pump was repeatedly beeping with a hold error, and the feeding formula volume remained unchanged over several hours, indicating that the prescribed nutrition was not being delivered. The nurse responsible confirmed that the pump should have been running continuously, and the DON stated that staff are expected to monitor and respond to feeding pump alarms. The facility's policy requires medications and treatments to be administered in accordance with prescriber orders, but this was not done in this case.