Failure to Provide Timely Admission Orders and Medications
Penalty
Summary
The facility failed to ensure that a newly admitted resident received complete and timely physician orders for immediate care upon admission. The resident, who had a complex medical history including a right femur fracture, acute kidney failure, chronic congestive heart failure, diabetes, obesity, bipolar disorder, anxiety disorder, hypertension, COPD, and leukemia in remission, did not receive essential medications such as insulin, cardiac drugs, pain medication, and psychotropic drugs. Documentation showed that only two doses of pain medication were administered, and there was no evidence that other critical medications or blood sugar checks were provided as ordered by the hospital discharge summary. Multiple staff interviews revealed confusion and lack of clarity regarding responsibility for entering and verifying admission orders. Nursing staff reported not having access to the necessary orders in the system and were unsure who was responsible for completing the admission process. The resident repeatedly requested pain medication and other necessary treatments but was told by staff that they were not in the system and had no medications available. The resident experienced significant pain and distress, ultimately leading to their decision to leave the facility with family assistance after contacting the police. The facility's own policy required informing the physician of admission, verifying transfer and admission orders, initiating required treatments, and ordering medications from the pharmacy. However, these steps were not completed in a timely manner, resulting in the resident not receiving critical medications and care. Staff interviews confirmed that the delay in obtaining and entering orders led to the resident's unmet medical needs and unnecessary pain during their stay.