Failure to Prevent Neglect and Medication Errors
Penalty
Summary
The facility failed to protect residents from neglect by not providing physician-ordered tube feeding and failing to assist a resident in getting out of bed for 13 days, resulting in a decline in the resident's functionality. The resident, who was admitted with multiple serious diagnoses including sepsis, acute respiratory failure, and protein-calorie malnutrition, was supposed to receive enteral nutrition via a tube feed and assistance with mobility. Observations and interviews revealed that the tube feeding was inconsistently administered due to issues with the pump and lack of staff knowledge, and the resident was not assisted out of bed because staff were waiting on therapy and a wheelchair was missing. Documentation showed missed and undocumented feedings, and the resident experienced weight loss and a decline in physical function during this period. Additionally, the facility failed to administer medications in accordance with physician orders for two residents. One resident did not receive all prescribed doses of an IV antibiotic due to pharmacy supply issues and lack of proper tracking, resulting in missed doses and the premature removal of a PICC line before the antibiotic course was completed. Staff interviews confirmed confusion and lack of communication regarding the medication schedule, and documentation did not support that the full course was administered as ordered. Another resident received the wrong IV medication due to a medication administration error involving two LPNs, one of whom was not IV certified. The error was not fully investigated, and required neurological assessments were not completed as ordered. Facility policies on medication administration and abuse prevention were not followed, and staff involved did not receive appropriate education or oversight regarding medication rights and administration procedures.