Failure to Meet Professional Standards in Medication Reconciliation, Documentation, and Order Implementation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for three residents. For one resident newly admitted with multiple complex diagnoses, including heart failure and dementia, the facility did not complete medication reconciliation or physician notification at the time of admission. The resident's family brought in topical antifungal medications and a list of home hospice medications, but many of these, including critical cardiac and dementia medications, were not ordered or administered. The admission checklist, which required reconciliation of medications and physician approval, was not completed by the admitting nurse, resulting in the omission of 17 medications from the resident's regimen. Another resident with severe cognitive impairment had a healthcare proxy (HCP) activated prior to admission, with the HCP making all medical decisions. Despite this, the required HCP invocation/activation form, which documents the physician's determination of incapacity, was not completed or present in the medical record. Interviews with facility staff and the physician confirmed that the form was missing and should have been completed at the time the HCP was activated. A third resident with dementia and heart failure had a physician's telephone order to discontinue two dementia medications. However, the DON did not discontinue these medications in the electronic health record, and the resident continued to receive them for several days after the discontinuation order. This failure to implement physician orders in a timely manner was confirmed through record review and staff interviews.