Failure to Administer Medications and Treatments Due to Staffing Refusal
Penalty
Summary
The facility failed to follow physician's orders for 19 residents on the 100 hall, resulting in missed administration of critical medications and treatments. The review of medical records and medication administration records revealed that residents with diagnoses such as Type II Diabetes Mellitus, Hypothyroidism, Coronary Heart Disease, pneumonia, COPD, and Muscular Dystrophy did not receive prescribed medications, including various types of insulin, Levothyroxine, antibiotics, pain medication, and inhalation treatments. Blood sugar checks and other ordered care were also not performed as required by the residents' care plans and physician orders. The deficiency occurred during the night shift when only one nurse, an LPN, remained after the scheduled nurse for the 200 hallway left early. The LPN assigned to the 100 hallway refused to provide care or administer medications to the residents on that hall, stating discomfort with covering both hallways due to limited experience at the facility. The Director of Nursing (DON) was informed of the staffing issue and attempted to secure an agency nurse, who was expected to arrive by 11:00 P.M., but did not arrive until the morning. The DON left the facility after giving the keys to the LPN, who refused to accept responsibility for the 100 hallway. Throughout the night, no medications or treatments were administered to any residents on the 100 hallway. Staff, including a CNA, attempted to contact the DON to report the ongoing issue, but did not receive a response until after the shift. The following morning, the LPN confirmed to the DON that no care had been provided to the 100 hallway residents, and subsequently resigned. The facility did not provide a policy on medication administration when requested.