Failure to Follow Physician Orders and Professional Standards in Medication Administration and Monitoring
Penalty
Summary
The facility failed to provide care and treatment according to professional standards, facility policy, and physician's orders for multiple residents. For one resident with a cardiac pacemaker, staff did not ensure the functionality of a remote cardiac transmission device. The device was found to be nonfunctional for over a month, with no documentation of daily checks or monitoring as required by the care plan and facility policy. Staff interviews revealed a lack of awareness regarding the device's status, and the last successful transmission was several months prior to the survey. The resident and staff were unaware of the device's malfunction, and there was no evidence that the physician or representative had been notified of the missed transmission. Another resident did not receive several scheduled medications, including Bumetanide, Gabapentin, and Lactobacillus, due to the medications being unavailable in the facility. Nursing staff failed to notify the physician or APRN of the missed doses, as required by facility policy. Documentation did not reflect any communication with the provider regarding the medication omissions, and the medications were not reordered in a timely manner. The facility's policy required immediate action and provider notification when medications were unavailable, but this was not followed. A third resident with insulin-dependent diabetes experienced multiple episodes of hyperglycemia and hypoglycemia, some requiring additional treatment such as glucose gel or IM Glucagon. The clinical record lacked documentation of RN assessments, provider notification, or notification of the resident's representative following these episodes, despite physician orders and facility policy requiring such actions. Staff interviews indicated confusion about roles and responsibilities for assessment and notification, with LPNs reporting that only RNs were allowed to contact providers or assess residents after a change in condition. The documentation did not reflect adherence to the hypoglycemia management protocol or communication requirements.