Failure to Follow Physician Orders, Medication Administration Standards, Skin Monitoring, and Glucometer Quality Control
Penalty
Summary
The facility failed to implement physician and hospice orders for bowel management for a resident with dementia and on hospice care. Despite clear orders to administer laxatives and notify the provider if there were three days without a significant bowel movement (BM), documentation showed multiple extended periods without a BM, and no evidence of provider notification or escalation of interventions. The resident's care plan and assessments did not address bowel issues, and staff interviews confirmed a lack of awareness and follow-through on bowel protocols, resulting in the resident being sent to the emergency room for constipation-related discomfort. In addition, the facility did not follow professional standards for eye drop administration for two residents. Observations revealed that a trained medication aide failed to use proper technique, including not pulling down the lower eyelid and allowing the tip of the bottle to touch the eye, which is contrary to accepted practice. The aide also administered more drops than ordered in one case. The DON confirmed there was no specific training or policy for eye drop administration, and the medication aide was unaware of proper procedures. The facility also failed to comprehensively assess and monitor significant bruising and a contusion for a resident on anticoagulation therapy. Weekly skin assessments lacked documentation of measurements or characteristics of bruises, and new contusions were not promptly identified or documented. Staff interviews indicated there was no expectation or process for ongoing monitoring of bruises, and the DON was unaware of new injuries until informed by surveyors. Additionally, the facility did not perform required quality control checks on glucometers used for blood glucose monitoring, with logs showing no quality control for nearly two months despite frequent use and unusually high blood sugar readings. Manufacturer and facility policy required quality control with each new bottle of test strips and when abnormal readings occurred, but this was not followed.