Failure to Follow Physician Orders and Inadequate One-to-One Supervision
Penalty
Summary
The facility failed to follow up with a resident's primary care physician or VA physician to obtain medication orders after filled prescription bottles were found in the resident's room following a medical appointment. The resident, who had a history of stroke, traumatic brain injury, and cognitive impairment, returned from a VA appointment with new prescriptions for Diphenhydramine and Prednisone. Facility staff removed the medications from the resident's possession but did not document the removal, did not clarify the orders with the prescribing physician or the facility's primary care physician, and did not enter the new medication orders into the resident's medical record. The resident repeatedly requested the medications, expressing discomfort and symptoms related to their absence, but staff failed to administer them or ensure proper follow-up, as required by facility policy and professional standards of practice. Additionally, the facility failed to provide care consistent with professional standards during one-to-one observation for two residents with behavioral health diagnoses. Both residents were placed on one-to-one supervision due to behavioral concerns, including smoking in the room and aggressive or erratic behaviors. However, staff assigned to observe the residents sat in the hallway with the door closed, rather than maintaining line-of-sight or arm's length supervision as required by facility policy. This lapse in supervision allowed a physical altercation to occur between the two residents, during which one resident threatened the other with a knife. Interviews with staff and facility leadership confirmed that the expected practice was for staff to remain within arm's length or at least in direct line of sight of residents on one-to-one observation. Staff admitted to not following this protocol, citing personal discomfort and misunderstanding of the requirements. Facility policies and leadership statements emphasized the importance of direct supervision and proper documentation, both of which were not followed in these incidents.