Failure to Maintain Essential Medical Supplies Resulting in Neglect
Penalty
Summary
The facility failed to ensure residents were free from neglect by not maintaining adequate supplies necessary to meet residents' medical needs. For one resident with dementia, chronic inflammatory demyelinating polyneuritis, and a stage 4 pressure ulcer, the required wound care supplies, specifically Anasept cleanser, were not available from 10/31/2025 onward. As a result, prescribed wound care treatments were not performed as ordered, and the resident's wound condition worsened. Documentation and interviews confirmed that the nurse management team and DON were aware of the supply shortage, but the Anasept was not reordered in a timely manner, leading to missed treatments and a significant decline in the resident's health, ultimately resulting in death from osteomyelitis and sepsis as noted by the nurse practitioner. Another resident with type I diabetes and diabetic polyneuropathy did not receive scheduled blood glucose monitoring or insulin doses due to the facility running out of blood glucose monitoring strips. The medication administration records showed missed blood glucose checks and insulin administrations over multiple scheduled times. Staff and the DON confirmed that the facility did not have a backup supply of strips, and no alternative methods were used to obtain them when the pharmacy could not provide any. The resident's blood glucose was not checked for four consecutive scheduled times, and insulin doses were missed, with a critically high blood glucose level documented once strips became available again. In both cases, the facility's failure to maintain essential medical supplies directly resulted in the inability to provide necessary care as ordered by physicians. The lack of timely supply management and failure to implement contingency plans led to significant lapses in care for residents with complex medical needs.