Failure to Administer Medications and Provide Supervision During Influenza Outbreak
Penalty
Summary
The facility failed to protect residents from neglect by not ensuring prescribed medications were administered, failing to notify physicians of missed medications, and not providing appropriate supervision and monitoring during a period of increased resident illness and high acuity related to an influenza outbreak. On the night in question, only one RN was present in the facility from approximately midnight to 7:00 AM, responsible for all 58 residents, including those on two separate units. This staffing shortage resulted from a nurse calling in sick, with no documented attempts by facility leadership to secure replacement coverage, and no nurse being assigned to one of the units. The facility's daily assignment sheets and timecards confirmed that only one licensed nurse was present during this critical period, and the facility's contingency plan for staffing emergencies was found to be inadequate and lacking actionable processes. Multiple residents did not receive their scheduled medications, including pain medications, antibiotics, and other essential treatments. For example, one resident did not receive morning doses of hydrocodone, Lasix, or gabapentin; another missed doses of pregabalin, sodium chloride, and other medications; and a resident on IV antibiotics did not receive scheduled doses. Medication Administration Records and controlled drug logs confirmed these omissions, and interviews with residents and staff corroborated that medications were missed and not administered as ordered. Additionally, the facility failed to notify physicians of these missed medications, and the medical director was unaware of the situation until informed by surveyors. During the influenza outbreak, the facility did not identify the outbreak in a timely manner, failed to initiate droplet precautions, did not notify the health department, and did not provide timely antiviral treatment or maintain outbreak surveillance and staff illness tracking. The facility's policies required adequate staffing and oversight, but these were not followed, and the Quality Assurance and Performance Improvement (QAPI) program did not identify or correct the systemic failures in infection control and staffing. Interviews with staff and leadership confirmed a lack of clear direction regarding nursing coverage responsibilities, insufficient oversight, and a lack of timely physician notification for missed medications, placing all residents at risk during the outbreak.
Removal Plan
- The Administrator held an emergency Quality Assurance and Performance Improvement (QAPI) meeting with the Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse, and others as part of the Interdisciplinary team to discuss findings from the State Agency, discuss immediate actions, and further interventions. Immediate actions included in-servicing all staff on Abuse and Neglect, in-servicing nurses on medication administration and medication errors, in-servicing all staff on flu outbreak and isolation precautions, reviewing policy for QAPI for any changes needed and as re-education in policy, reviewing and updating facility assessment to identify updated needs to staff per unit and the contingency plan for emergencies, completing a 100 percent audit on all medication carts compared to medication orders to ensure all medications were accessible in the building, in-servicing the Infection Preventionist on roles and responsibilities, and reviewing and updating policies on Abuse and Neglect, medication administration, medication errors, QAPI, flu outbreak, isolation precautions, and expectations of the Infection Preventionist. Staff were in-serviced with new policies.
- The Administrator notified the Medical Director of missed medications during the QAPI meeting. All missed medications were reviewed with the Medical Director. No new orders were given. No adverse reactions were noted due to missed medications.
- The Director of Nursing began an in-service for all staff on the policies and procedures of Abuse and Neglect. No employee was permitted to return to work until they completed the in-service.
- The Director of Nursing began an in-service on medication administration and medication errors to educate all nursing staff. This in-service included procedures for when medication cannot be located anywhere in the facility. If medication is not available, staff should contact pharmacy and pull medication from emergency kit. Any missed medications are to be reported to the Director of Nursing and Medical Director immediately, an incident report is to be completed, the resident observed for any adverse reactions, and the family/resident representative is to be notified. Any tasks left undone are to be reported to relief during report for oncoming shift. No employee was permitted to return to work until they completed the in-service.
- Administrator and Director of Nursing reviewed Flu outbreak and Isolation precautions policy and procedures. The Director of Nursing began an in-service for flu outbreak and isolation precautions to educate all staff. All staff are to continue to monitor residents and staff for flu-like symptoms and report any findings to the immediate supervisor. No employee was permitted to return to work until they completed the in-service.
- The Administrator reviewed policy on Quality Assurance and Performance Improvement plan and policy for re-education purposes and to review new policy. The QAPI plan and policy was reviewed with the facility's Interdisciplinary Team including the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others in a follow up QAPI meeting.
- The facility Administrator began reviewing and updating the facility assessment to reflect correct staffing and supervision by shift and by unit related to the facility's acuity level. The Facility Administrator began updating the contingency plan for staffing emergencies within the facility assessment. The contingency plan will be initiated and is as follows: Facility will utilize On-call for staffing needs and call ins. On-call will notify Director of Nursing if not able to cover. Facility will utilize Consultants and/or transfer staff from other nursing facilities within partnership to assist and cover staffing needs. The new facility assessment was reviewed with the interdisciplinary team during follow up QAPI.
- The Infection Preventionist (IP) was included in an in-service held by the Director of Nursing for policy and procedures of outbreak surveillance and staff-illness tracking during an outbreak to be completed before beginning of their next shift. Due to this outbreak being finished, IP nurse was instructed to continue to monitor residents and staff for flu-like symptoms and to report to Director of Nursing any findings.
- The Director of Nursing, Medical Records nurse, and Wound Care nurse completed a 100 percent audit to compare the current medication orders to the medication on the carts and in medication rooms to verify all medications ordered were readily available in the facility. No negative findings during audit.
- The Administrator notified the Mississippi Department of Health of the flu outbreak.
- The Administrator held a follow-up QAPI meeting to discuss all immediate actions that were in place. All in-services and audits were completed. All staff would continue to monitor any residents or staff for flu-like symptoms, staffing would be reviewed daily to ensure all areas were covered according to the facility assessment, and daily reviews of missed medications would be reviewed each morning in clinical meeting.