Failure to Provide Appropriate Care and Medication Management
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for two residents. One resident, admitted with heart disease, muscle weakness, and lack of coordination, was dependent on staff for activities of daily living and was cognitively intact. Despite expressing a desire to participate in activities such as going outside, to the dining room, and shopping, the resident remained in bed most of the time due to discomfort and pain caused by an ill-fitting and uncomfortable wheelchair. Multiple staff interviews confirmed that the resident's complaints about the wheelchair were reported to nursing staff, but no timely referral or assessment for a more suitable wheelchair was initiated. The resident continued to experience discomfort, and only after several days was a cushion replaced, which did not resolve the underlying issue with the wheelchair's fit and support. Another resident, admitted with a history of chronic pain, depression, and insomnia, did not receive their long-term use medications as ordered upon admission. The resident's pain medication (oxycodone) was not available for nearly 36 hours after admission, and their prescribed antipsychotic medication (Seroquel) was discontinued and replaced with an over-the-counter supplement without their knowledge. The resident experienced significant distress, including pain, withdrawal symptoms, and worsening depressive symptoms. The medication administration records showed repeated interruptions in the provision of both oxycodone and Seroquel, with periods where the medications were not reordered or were abruptly discontinued and restarted multiple times. Provider notes documented the resident's ongoing complaints and distress related to these medication issues. The failures in both cases were confirmed through observation, interviews with residents and staff, and review of medical records and medication administration records. The lack of timely assessment and intervention for the wheelchair issue, as well as the failure to provide and manage essential medications according to orders and standards of practice, resulted in residents experiencing pain, discomfort, and emotional distress.