Failure to Reconcile Admission Orders and Incomplete Care Planning Leads to Resident Harm and Death
Penalty
Summary
The facility failed to protect a resident from neglect by not providing necessary services to prevent physical harm, pain, mental anguish, and emotional distress. Upon admission, the resident had multiple complex medical conditions, including schizophrenia, major depressive disorder, narcolepsy with cataplexy, osteoporosis, fractures, diabetes, and a recent urinary tract infection. Hospital discharge orders included several critical medications such as antibiotics, sliding scale insulin, lidocaine patches, and a high-dose antipsychotic (Seroquel). None of these orders were implemented upon admission due to incomplete scanning and reconciliation of the discharge paperwork, resulting in the resident not receiving essential treatments for infection, diabetes management, and psychiatric stabilization. Staff interviews revealed that the medication reconciliation process was inadequate, with nurses and administrative staff only reviewing the medication list and not the full discharge summary. This led to missed orders for antibiotics, insulin, and pain management, as well as the omission of the resident’s long-term antipsychotic medication. The resident subsequently experienced withdrawal symptoms, exacerbation of psychiatric symptoms, repeated falls, and major injuries, including subdural hematomas and a fractured foot. The care plan and fall risk assessments were inaccurate and incomplete, failing to address the resident’s increased risks due to missed medications, changes in condition, and high-risk diagnoses such as narcolepsy with cataplexy and multiple fractures. Despite multiple incidents of falls, behavioral changes, and hospitalizations, the care plan was not updated with appropriate interventions to address the resident’s deteriorating condition and increased safety risks. The facility also accepted the resident back from the hospital with orders for IV antibiotic therapy, which it was not equipped to provide, resulting in further delays in care. The resident ultimately died from complications related to repeated falls and untreated medical conditions, with the manner of death listed as an accident due to blunt force trauma of the head. The facility did not implement an incident report when the medication error was discovered and failed to review the complete discharge paperwork to identify all missed orders.