Failure to Administer Critical Medications and Provide Wound Care
Penalty
Summary
The facility failed to meet the medical needs of two residents, resulting in significant deficiencies. One resident was admitted with end stage renal disease and a recent kidney transplant, requiring strict adherence to a complex medication regimen including multiple immunosuppressants and specific wound care for a surgical site. Upon admission, the facility did not document a review of the medication list with the facility physician, failed to ensure the availability and administration of critical anti-rejection medications, and did not provide the ordered wound care for two and a half days. Staff documented that medications were not given because they were waiting for pharmacy delivery, despite the medications being sent with the resident from the hospital. There was also a lack of documentation and communication regarding the resident's transplant status, infection control needs, and high-risk medication protocols in the care plan. The facility's staff, including the DON, LPNs, and CMTs, demonstrated a lack of knowledge and training regarding the care of post-transplant residents and the importance of timely administration of high-risk medications. Interviews revealed that staff were unaware of the significance of missed doses, did not know who was responsible for ensuring medication availability, and failed to notify the resident's physician or transplant team about missed medications and wound care. The wound care nurse and other staff expressed discomfort and lack of experience with the required wound care, leading to further delays. Attempts by the resident's transplant team to communicate with facility staff were unsuccessful, and the transplant team was not informed of the missed medications or wound care lapses. As a result of these failures, the resident was admitted to the hospital with undetectable levels of anti-rejection medication, sepsis, and a necrotic surgical wound, requiring IV antibiotics and multiple surgeries. In a separate incident, another resident did not have their psychotropic medications reconciled or administered, leading to behavioral outbursts and eventual hospitalization for psychiatric care. The facility's policies for medication administration, wound care, and special needs management were not followed, and there was a breakdown in communication and documentation at multiple levels of staff responsibility.