Failure to Prevent Resident Neglect in Medication Administration and Dietary Needs
Penalty
Summary
The facility failed to prevent neglect for two residents. One resident reported that LPNs often let him run out of medication, resulting in missed doses of Gabapentin, Ropinirole, and Synthroid, despite these medications being available in the pyxis system. Review of the medication administration record confirmed that several doses were not documented as administered, and a registered nurse verified that the medications were accessible but not given by the on-duty nurse. The resident experienced discomfort due to missing his medication for restless leg syndrome. Another resident requested a snack for over 30 minutes, specifically asking for a peanut butter sandwich. Multiple staff were present and could have responded, but the resident was not provided with a snack until much later. When a sandwich was finally given, it was not the correct consistency for her prescribed pureed diet. The sandwich was then taken away by a nurse aide, which upset the resident. The resident declined alternative snacks and expressed unhappiness about not receiving the requested food. The correct snack was not provided until nearly an hour after the initial request.