Failure to Provide Care and Administer Medications as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals, as evidenced by multiple incidents involving eight residents. In several cases, residents did not receive prescribed medications as ordered. For example, one resident was prescribed Macrobid for a urinary tract infection but only received the medication for four days instead of the five days ordered, despite the medication being available in the facility's stock. Another resident did not receive several medications, including antibiotics and pain medications, upon admission and after hospital discharge, as documented in the Medication Administration Record and confirmed by the Director of Nursing. There were also failures in post-fall care and documentation. Two residents experienced unwitnessed falls, and although neuro checks and vital signs were ordered and noted as necessary, there was no documentation that these assessments were performed after the incidents. In one case, a resident was found unresponsive and expired after a fall, with no evidence of neuro checks being conducted between the fall and the discovery of the resident's condition. Another resident's representative reported a lack of information regarding the resident's fall and subsequent transfer to the hospital, and the medical record lacked documentation of neuro checks or assessments following the fall. Additional deficiencies included failures in medication reconciliation and laboratory testing. One resident's medication list was not fully reconciled after readmission, and laboratory tests recommended by a nurse practitioner were not ordered until after surveyor intervention. There were also instances where residents received incorrect medications, missed doses of IV antibiotics, and changes in medication dosages without proper communication or documentation. In one case, a resident with diabetes experienced multiple episodes of hypoglycemia, including a critical event requiring emergency intervention, but there was no documentation of daily skilled assessments, vital signs, or physician notification of low blood sugars. These findings were confirmed through interviews with facility staff and review of medical records.