Failure to Follow Professional Standards and Physician Orders in Medication Administration and Repositioning
Penalty
Summary
Facility staff failed to follow professional standards of practice and physician orders in the care of two residents. In the first instance, a registered nurse prepared a Heparin injection for a resident with a history of Deep Vein Thrombosis using an intramuscular (IM) gauge and length needle, rather than the required subcutaneous (SQ) gauge and length needle. The nurse was unable to identify the correct equipment for subcutaneous administration when questioned, and the error was only prevented by surveyor intervention before the medication was administered. In the second instance, staff did not adhere to a physician's order and care plan requiring a resident with anoxic brain injury, chronic respiratory failure, and total dependence for activities of daily living to be turned and repositioned every two hours. Observations over a three-hour period showed the resident remained on her left side with pillows for pressure redistribution, despite staff claims that repositioning had occurred. The assigned CNA was unable to explain the discrepancy when questioned and only repositioned the resident after being prompted by the surveyor. Both deficiencies were substantiated through direct observation, record review, and staff interviews, demonstrating a failure to provide care and treatment according to professional standards, physician orders, and the residents' care plans.