Failure to Administer Medications and Provide Wound Care per Physician Orders
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with physician orders and professional standards, as evidenced by two separate incidents involving two residents. In the first case, a resident with a history of bipolar disorder, depression, and suicidal ideations did not receive her prescribed Wellbutrin XL 150 mg for depression as ordered. During a medication administration observation, the registered nurse reported the medication was not available and did not notify the provider or search for extra medication in the designated area. Further review revealed inconsistent documentation, with one nurse falsely documenting administration of the medication and later admitting the error. The medication had been available in the medication cart, but it was not administered as ordered, and the provider was not notified of missed doses. The nurse practitioner was unaware of the missed doses, despite the resident's complex psychological needs and recent medication adjustments due to worsening symptoms. In the second case, a male resident with a right foot trans metatarsal amputation, diabetes, and a history of foot ulcers did not receive wound care as ordered. The resident's care plan and physician orders specified twice-daily wound care, including cleansing and application of Bacitracin Zinc Ointment, as well as daily monitoring for signs of infection. However, review of the treatment administration record (TAR) revealed multiple omissions in the documentation and completion of wound care treatments. During an observation, the wound care nurse discovered that the resident's dressing had not been changed for several days, with the last documented change occurring several days prior. The nurse confirmed that the dressing should have been changed twice daily, as ordered, and that the omission was not due to resident refusal, as no refusals were documented in the record. Interviews with nursing staff and the director of nursing confirmed that treatments were not provided as ordered and that refusals, if they had occurred, were not documented according to facility policy. The facility's wound management policy requires that wound treatments be provided in accordance with physician orders and that refusals be documented and communicated to the provider. The failure to administer medications and provide wound care as ordered resulted in residents not receiving care in accordance with professional standards and physician directives.