Failure to Follow Physician Orders and Address Changes in Resident Condition
Penalty
Summary
The facility failed to follow physician orders and did not provide appropriate assessment and treatment for changes in residents' conditions, as evidenced by three separate cases. One resident with multiple myeloma was prescribed Venetoclax to be administered at specific times and in a specific manner, but the medication was given late on at least twenty-seven occasions. Staff acknowledged the delays, citing the resident's difficulty swallowing and the time required for administration, and stated that the medication was often given at the end of the medication pass. The resident and family members expressed concerns about the timeliness of medication administration, and staff confirmed that the medication was not consistently given within the required timeframe. Another resident with epilepsy and hemiplegia was prescribed Lacosamide to be administered twice daily at set times. Upon admission, the resident missed the first scheduled dose due to a script not being sent with the resident, and subsequent doses were administered late on multiple occasions. Staff interviews confirmed that antiseizure medications were expected to be prioritized and administered within a specific window, but this was not consistently achieved for this resident. A third resident with Parkinsonism reported persistent itching and suspected an allergic reaction to bedding, which resulted in frequent scratching and visible skin damage. The resident reported the issue to multiple CNAs, but the concern was not escalated to nursing staff or the physician. Observations confirmed the presence of scratch marks and bleeding, and staff interviews revealed that while some applied lotion, no further assessment or intervention was initiated, and the physician was not notified of the ongoing skin condition.