Failure to Administer Prescribed Treatments and Medications as Ordered
Penalty
Summary
The facility failed to ensure that prescribed treatments and medications were administered as ordered for two residents. For one resident with a history of dementia, cognitive communication deficit, and muscle weakness, there was a physician's order to apply Skin Prep to the left sacrum and cover with a bordered dressing every Monday, Wednesday, and Friday as a preventative measure following the healing of a Stage II pressure ulcer. However, observation and interviews revealed that the dressing was not changed according to the prescribed schedule. Documentation on the treatment administration record indicated that wound care was completed on certain dates, but interviews with nursing staff confirmed that this documentation was made in error, and the dressing had not been changed as required. Another resident with end stage renal disease, multiple comorbidities, and dependence on dialysis had a physician's order for sevelamer hydrochloride to be administered before meals as a potassium binder. Review of medication administration records and progress notes showed multiple instances over several months where the medication was not given because it was unavailable. Notes indicated repeated delays in receiving the medication from the pharmacy, and staff interviews confirmed confusion regarding the ordering process and significant delays in delivery. The resident reported not receiving the medication for extended periods and experiencing symptoms such as nausea and diarrhea during these gaps. Facility policy required that medication orders and receipt records be maintained and that medications be ordered in advance based on pharmacy lead times. However, the facility did not have a process to record the receipt of medications from the specific pharmacy supplying the sevelamer, and shipping invoices were incomplete. The lack of proper documentation, ordering, and follow-up led to the residents not receiving their prescribed treatments and medications as ordered.