Failure to Administer Ordered Treatments and Document Care
Penalty
Summary
Facility staff failed to provide appropriate treatment and care according to provider orders, resident preferences, and goals for multiple residents. In one instance, a resident with diabetes did not receive their ordered bedtime insulin upon admission, and there was no documentation of administration. The resident subsequently experienced a critically high blood sugar level, requiring emergency intervention and transfer to the hospital. Additionally, the same resident did not have their before-meal insulin ordered for the evening meal on the day of admission, resulting in a gap in diabetic management. Another resident with a physician's order for Gabapentin to be administered at bedtime for pain did not receive the medication on two separate days, despite the medication being available in the facility's backup medication dispensing system. Documentation indicated the medication was not available from the pharmacy, but the DON later confirmed it was accessible in the Cubex system and should have been administered as ordered. The order was discontinued after several missed doses. A third resident with orders for daily weights due to congestive heart failure did not have weights consistently obtained or documented. The electronic medication administration record (eMAR) lacked a designated area for weight documentation until several months after the order was in place, and staff were signing off on weights without actually performing them. Progress notes indicated multiple refusals by the resident, but the weight record showed infrequent documentation of actual weights, and the DON confirmed that nurses were not consistently obtaining the weights as ordered.