Failure to Ensure Professional Standards in Medication Administration and Resident Admission
Penalty
Summary
The facility failed to ensure that nursing staff met professional standards of quality in the care of newly admitted residents and in the administration of medications. In one instance, a nurse was not informed that he was responsible for a newly admitted resident with multiple complex medical conditions, including diabetes, congestive heart failure, and a gastrostomy tube. As a result, the nurse did not reconcile or administer the resident's medications as ordered, nor did he check the resident's blood sugar or review the resident's medical history upon admission. The nurse only became aware of the resident's presence and his responsibility for the resident after being called to address bleeding at the gastrostomy site later in the evening. The electronic medical record did not provide access to the necessary orders or hospital discharge summary, further impeding care. The resident did not receive several scheduled medications, including Atorvastatin, Alprazolam, Gabapentin, and Carvedilol, and there was no documentation of required blood sugar checks on the night of admission. Additionally, the facility failed to ensure that nurses were knowledgeable about a newly admitted resident's medical history and could access this information when assigned to the resident. Both the evening and night shift nurses reported being unable to view the resident's orders or hospital discharge summary in the electronic system, resulting in incomplete care and lack of medication administration. The nurse practitioner confirmed that the lack of a blood sugar check the night before did not directly impact the resident's blood sugar control the following day, but the documentation and communication failures were evident. In a separate incident, another resident with Parkinson's disease did not receive a scheduled dose of carbidopa-levodopa, a medication ordered to be administered every four hours. The medication administration record showed that one dose was missed, and the resident reported experiencing increased tremors and some confusion as a result. The nurse aide was informed by the resident about the missed dose but did not communicate this to the nurse, assuming the nurse would administer the medication. The nurse later stated that the medication was given late due to unfamiliarity with the hall and the resident's room location. The director of nursing and administrator were unaware of the missed dose until after the fact.