Failure to Follow Medication Orders and Supervise Substance Use
Penalty
Summary
The facility failed to administer medications according to physician orders and did not provide appropriate supervision and assessment for a resident with a history of illicit substance use. For one resident, staff repeatedly administered midodrine despite blood pressure readings above the physician-ordered threshold for holding the medication. Documentation showed multiple instances over two months where the medication was given when the systolic blood pressure exceeded 120 mmHg, contrary to the order and facility policy requiring vital sign monitoring and adherence to parameters before administration. In a separate incident, another resident with a diagnosis of cirrhosis and moderate cognitive impairment was found to have drug paraphernalia in their room, including a broken glass pipe with a white substance, foil, scissors, and a burned light bulb. Staff did not complete an incident report, notify the police, or document how the paraphernalia was discarded. The resident's care plan did not include goals or interventions related to substance use, and there was no documentation of assessment upon the resident's return to the facility after outings, despite a policy requiring such assessments for signs of substance use or overdose. Additionally, sign-out sheets for the resident were incomplete, lacking reasons for outings and times, and progress notes did not reflect required assessments upon return. The facility's administration was not made aware of the incident until prompted by surveyors, and the Director of Nursing confirmed that the required monitoring and documentation were not performed as per policy.