Failure to Administer Medications and Treatments as Ordered and Documented
Penalty
Summary
Facility staff failed to administer medications and treatments according to physician orders, facility policy, and residents' preferences and goals. During medication pass observations, it was found that medications scheduled for administration at 9:00 AM were instead given after 12:00 PM to a resident with severe cognitive impairment, and the administration times were inaccurately documented as 9:00 AM in the Medication Administration Record (MAR). Staff involved admitted to not knowing how to document the correct administration time. In another case, a resident with good mental cognition received medications significantly later than scheduled, and the MAR was again inaccurately completed to reflect the scheduled, not actual, administration time. Staff acknowledged that the medications were late but believed it was acceptable within a certain window. Additionally, the facility failed to follow physician orders for topical treatments. One resident with no cognitive impairment had antifungal cream prescribed to be applied twice daily to the feet, but the resident reported that nurses were not applying the cream and that he was unable to do it himself. The cream was found at the bedside, not on the medication cart as required, and staff had documented in the record that the treatment was provided, contrary to the resident's statements and physical evidence. Another resident, also with no cognitive impairment, had a similar order for antifungal cream to be applied every shift, but reported self-application and denied nurse involvement, despite staff documentation indicating otherwise. Staff had difficulty locating the cream and could not confirm its application when questioned. A further deficiency was identified in the care of a resident with impaired skin integrity and multiple comorbidities, including diabetes and hemiplegia. The care plan required specific wound care treatments, including the application of silver sulfadiazine cream twice daily. Observations revealed that the cream was being applied by a CNA using a tongue depressor from a cup, and staff interviews indicated confusion about who was responsible for the application and the frequency. The wound care nurse and other staff provided inconsistent information regarding the treatment schedule and responsibility, and the documentation did not align with the actual care provided.