Failure to Administer Ordered Medications and Wound Treatments
Penalty
Summary
The facility failed to ensure that prescribed treatments and medications were administered as ordered for two residents. One resident with multiple comorbidities, including osteomyelitis, pressure ulcers, and morbid obesity, developed a facility-acquired pressure ulcer on the left lateral malleolus. The wound care clinic recommended a collagen/silver combination dressing for this wound, with instructions to change the dressing daily and a supply provided for 30 days. However, the facility was unable to consistently apply the recommended dressing due to a reported shortage of the product, and instead used a different dressing (calcium alginate with silver) that was not in accordance with the wound clinic's orders. Interviews with nursing staff revealed uncertainty about whether alternative suppliers or other corporate facilities were contacted to obtain the correct dressing, and documentation showed ongoing use of the non-recommended product. Another resident, admitted with a history of stroke, hypertension, and other conditions, did not receive her prescribed blood pressure medication, Nifedipine, for multiple days following admission. The medication was not available in the facility or from the backup pharmacy, and repeated documentation indicated ongoing communication with the pharmacy and the nurse practitioner about the unavailability. The resident expressed distress about not receiving her medication, which was ordered to be given four times daily. Despite care plan interventions specifying the need to administer medications as ordered and monitor for complications related to hypertension and recent intracranial hemorrhage, the medication was not administered as prescribed for an extended period. In both cases, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and physician recommendations. The failure to provide the ordered wound care treatment and to administer essential blood pressure medication as prescribed constituted a deficiency in the quality of care provided to these residents.