Failure to Honor Resident Preferences and Physician Orders for Medication Administration and Positioning
Penalty
Summary
The facility failed to honor a resident's preferences as ordered by the physician, specifically regarding medication administration and positioning before meals. The resident, who had severe cognitive impairment and multiple physical limitations, had a physician's order for medications to be crushed and given only with pudding or yogurt, and to be assisted out of bed before lunch and returned to bed after lunch as tolerated. Despite these orders, staff administered medications with applesauce when yogurt was unavailable in the unit, even though yogurt was present in the kitchen. Staff confirmed the resident's preference for yogurt and acknowledged not checking the kitchen supply. Additionally, staff did not consistently assist the resident out of bed before lunch, as ordered, and documented completion of this task in the MAR/TAR without actually performing it or documenting any refusals by the resident. Multiple observations showed the resident remained in bed during lunch and was not assisted out of bed as required. Interviews with staff confirmed that the resident was not routinely assisted out of bed before lunch, and that refusals were not documented. The failure to follow physician orders and honor the resident's preferences was corroborated by staff interviews, medical record reviews, and direct observations, demonstrating a lack of adherence to both the resident's rights and prescribed care.