Failure to Administer and Reconcile Hospice Medications Results in Resident Neglect
Penalty
Summary
The facility failed to protect residents' rights to be free from neglect by not ensuring that medications were obtained and hospice orders were followed for two residents admitted for hospice respite stays. In the first case, a resident with multiple complex diagnoses, including epilepsy and diabetes, was admitted without a clear medication reconciliation process. Despite having the hospice medication list and being informed that the family was to provide medications, nursing staff did not locate the medications in the resident's belongings, did not notify the physician or hospice provider for clarification, and did not order the necessary medications from the pharmacy. As a result, the resident did not receive critical medications, including anticonvulsants and insulin, leading to a witnessed seizure and subsequent hospitalization. In the second case, another resident admitted for hospice respite care also experienced a failure in medication management. The resident arrived with her home medications, and the facility had two conflicting medication lists—one from the emergency room and one from hospice. The facility did not clarify which list to follow with the hospice provider or physician, nor did they ensure that scheduled medications for comfort and symptom management, such as Quetiapine and Ambien, were entered into the electronic medical record or administered. The resident's medications remained untouched in her belongings throughout her stay, and the lack of appropriate medication administration contributed to increased restlessness and discomfort during her end-of-life care. Interviews with staff, family members, and hospice providers confirmed that the necessary medications were either present with the residents or could have been obtained promptly if ordered. The facility's own policies defined neglect as the failure to provide goods and services necessary to avoid physical harm or emotional distress, and staff acknowledged that the residents should have received their medications. The documentation and interviews revealed a lack of communication, failure to follow established procedures, and inadequate assessment and response to the residents' medication needs.