Widespread Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors by not administering all prescribed medications and treatments in a timely manner, as required by physician orders and facility policy. One resident with insulin-dependent diabetes mellitus was discharged from the hospital with orders for daily insulin glargine and blood glucose monitoring, but upon review, there were no active orders or documentation in the electronic medical record for insulin administration or finger stick blood sugar checks. The nurse responsible for admitting the resident stated she remembered entering the orders, but they were not present in the system, resulting in the resident not receiving critical diabetes management. A comprehensive review of the facility's missed and late medication reports revealed widespread issues, with thousands of pages documenting missed and late administration of various medications and treatments for multiple residents. These included essential medications for conditions such as pain, diabetes, anticoagulation, schizophrenia, anxiety, asthma, hypertension, seizures, depression, and more. Additionally, required treatments and assessments such as wound care, vital sign monitoring, and diabetic foot checks were not completed as ordered. The DON confirmed that these medications and treatments were not administered according to prescriber orders or facility policy, and the Medical Director was unaware of the extent of the missed and late administrations.