Failure to Administer Medication and Wound Care as Ordered
Penalty
Summary
The facility failed to ensure that wound treatments and medication administration were provided as ordered for two residents. One resident with Type 2 Diabetes Mellitus, diabetic neuropathy, major depressive disorder, and anxiety disorder did not receive her prescribed weekly diabetes medication, Mounjaro, on three out of six scheduled occasions. Documentation showed that the medication was unavailable on those dates, and there was no evidence that the facility physician was notified of the missed doses. Progress notes indicated that the nurse did not document contacting the pharmacy or physician, and the DON confirmed that staff are expected to reach out to both and document these actions when a medication is unavailable. Another resident with dementia, peritoneal abscess, cutaneous abscess of the abdominal wall, major depressive disorder, and bipolar disorder had a wound requiring dressing changes every eight hours. The treatment administration record showed that several scheduled dressing changes were not documented as completed, and there was no documentation explaining the missed treatments. The resident reported that dressing changes were sometimes missed, and the DON confirmed that there was no documentation of the rationale for the missed wound care. Both deficiencies were identified through observation, interview, and record review, revealing a lack of adherence to physician orders and facility policy regarding medication and wound care administration. The failures included missed doses and treatments, lack of documentation for missed care, and insufficient communication with the physician and pharmacy as required by facility policy.