Failure to Administer Medications Timely and Manage Pressure Wound per Standards
Penalty
Summary
Facility staff failed to administer physician-ordered medications within one hour of the scheduled time for multiple residents. Medication administration records and audit reports showed repeated delays in giving scheduled medications, with some doses being administered several hours late. There was no evidence in the clinical records that the ordering provider or attending physician was notified of these delays. Interviews with staff confirmed that blanks in the medication administration record indicated missed doses, and that late administration should be reported to the physician, but this was not documented as having occurred. One resident with an advanced pressure wound did not receive appropriate management according to professional standards of care. After a pressure ulcer was identified, there were no physician orders for the initial wound treatment, and no evidence that wound care was provided for several days. Recommendations from the wound specialist, including changes in treatment and diagnostic imaging, were not implemented in a timely manner. Documentation showed significant delays in starting recommended treatments and obtaining an x-ray, with the wound deteriorating to a Stage 4 ulcer with visible bone exposure. The facility's own policy required prompt implementation of wound care orders and regular documentation of repositioning, which was not consistently done. Interviews with residents and staff revealed that some residents were aware of missed or delayed medications, while others were non-verbal and could not be interviewed. Staff interviews confirmed that medications should be administered within one hour of the scheduled time and that late administration should be reported to the physician. Facility policies and professional nursing standards cited by the facility emphasized the importance of timely medication administration and proper wound care, but these standards were not consistently followed, resulting in deficiencies in care for several residents.