Failure to Ensure Lab Monitoring, Change of Condition Reporting, and Pain Medication Administration
Penalty
Summary
The facility failed to ensure appropriate laboratory testing and monitoring for several residents receiving medications that require such oversight. One resident was prescribed cholesterol-lowering and uric acid-lowering medications without any documented lab results for cholesterol or uric acid levels, and there was no diagnosis related to high uric acid. Staff acknowledged that these labs should have been obtained prior to medication administration. Another resident with hypothyroidism received daily thyroid hormone replacement without documentation of a Thyroid Stimulating Hormone (TSH) test to monitor therapy effectiveness. The facility also failed to observe and report changes in condition for residents at risk. One resident with diabetes and a history of heart failure reported that staff did not remove their socks or check their legs for swelling, resulting in undetected edema for three weeks. Another resident dependent on dialysis had redness, swelling, and pain in their right hand, which staff failed to notice or report during routine care, despite care plans instructing staff to monitor for such changes. Additionally, the facility did not administer pain medications as ordered for a resident with a history of vertebral fracture and chronic pain. The resident received a lower dose of pain medication than prescribed on multiple occasions, and a pain patch was not applied as soon as it was available, contrary to physician orders. Staff interviews confirmed that medication administration did not follow the prescribed pain management protocol.