Failure to Provide Care and Treatment According to Orders and Standards
Penalty
Summary
Facility staff failed to provide treatment and care services in accordance with professional standards of practice for multiple residents, as evidenced by several documented incidents. For one resident with diabetes, staff did not follow standing orders for hypoglycemic management during a critical episode. Despite a blood glucose reading of 30, staff did not administer glucagon as required by protocol, and there was confusion and lack of documentation regarding the availability and administration of emergency medications. The resident was transferred to a higher level of care due to the unresolved hypoglycemic event. Another resident who experienced a fall and complained of hip pain did not receive a timely x-ray as ordered by the medical provider. The x-ray, which was supposed to be performed promptly, was delayed over the weekend, and staff failed to notify the provider about the delay. The resident continued to report pain, and only after several days was sent to the hospital, where a hip fracture was diagnosed, requiring surgical intervention. Documentation errors were also noted, with staff incorrectly recording that the x-ray had been completed when it had not. Additional deficiencies included failure to ensure a resident received a chest x-ray as ordered, with no evidence the procedure was completed or documented. In another case, staff did not administer Seroquel as ordered and failed to discontinue multiple medications per hospice instructions, resulting in discrepancies between the medication administration record and provider orders. There were also failures to follow medication orders related to a change in condition for another resident, with prescribed treatments not administered and incomplete documentation of assessments and interventions.