Failure to Provide Necessary Care, Medication Administration, and Dietary Safety
Penalty
Summary
The facility failed to provide necessary care and services by not recognizing and treating changes in condition, not following physician orders for medication parameters, failing to document medication administration, and not ensuring food was provided in the correct form. Multiple residents experienced harm as a result, including one resident who was hospitalized with respiratory failure, urinary tract infection, and aspiration pneumonia after staff failed to assess and notify a physician about abnormal urinary output and repeated episodes of distress. Another resident died after being given food despite an order for nothing by mouth (NPO), with the facility failing to protect the resident from others providing food. Medication administration errors were identified for several residents. Orders for side effect monitoring of psychotropic medications were not completed on multiple occasions, and insulin was held without a physician order. Residents received medications such as Midodrine and gabapentin outside of prescribed parameters, including administration when blood pressure was above the hold threshold and dispensing more doses than ordered. Documentation was lacking for medication and treatment administration, and in some cases, there was no evidence that required monitoring or physician notification occurred after abnormal findings. The facility also failed to ensure that residents' dietary needs were met according to orders. One resident did not receive prescribed hemorrhoid cream, with no documentation to support administration. Another resident with a profound swallowing disorder and NPO order died after choking on food, with the investigation failing to determine how the food was provided and no follow-up education for staff or residents with modified diets. These deficiencies were confirmed through record review, interviews, and observations, and were acknowledged by the Director of Nursing.