Failure to Follow Professional Standards in Medication Administration and Device Management
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards for two residents. For one resident with dementia who was cognitively intact and required assistance, there was a medication error involving Abilify, an antipsychotic. After a physician ordered a dose reduction from 5 mg to 2.5 mg at bedtime, the resident received both the old and new doses on the same night, totaling 7.5 mg. This occurred because the previous order was not discontinued when the new order was implemented, resulting in an extra dose being administered. The Director of Nursing confirmed the error during an interview. For another resident admitted with a hip fracture, indwelling urinary catheter, and a PICC line, the facility did not promptly address concerns regarding the continued need for these devices. The resident's family repeatedly expressed concerns to staff about the risk of infection and questioned the necessity of keeping the catheter and PICC line in place, especially since the PICC line was not being used. Staff did not contact the physician in a timely manner to clarify the ongoing need for these devices, despite the family's ongoing distress and requests for action. The Director of Nursing confirmed that staff should have acted more promptly to address these concerns.