Failure to Ensure Medication and Care Plan Approval for Residents Attending Day Programs
Penalty
Summary
The facility failed to follow physician orders and ensure proper continuation of care for two residents who were transported to day programs. Staff sent both residents to school without confirming that the school had received the required medications or that the residents' care plans had been approved. Interviews revealed that an LPN sent one resident to school without checking if the medications were at the school, and the school immediately called for the resident to be picked up as he was not approved to attend. The DON confirmed that although documents and medication orders were sent to the school, the medication supply had not yet been delivered, and staff sent a resident to school before these requirements were met. The Administrator and CNA also confirmed that residents were sent to school prematurely and had to be retrieved after the school notified the facility of the oversight. Resident B had diagnoses including epilepsy, convulsions, lack of coordination, and contracture of the right ankle, with orders for multiple anti-seizure medications to be provided during day services. Resident C had diagnoses of autism, epilepsy, and anxiety, with similar orders for anti-seizure medications. Both residents had care plans indicating a risk for seizures and required medications as ordered. Facility staff and the Social Services Director acknowledged that residents were sent to school without the necessary medications on hand and before care plan approval, contrary to the instructions from the school nurse. The facility did not have a policy in place regarding the process for residents attending school outside the facility.