Failure to Implement Emergency Plan and Timely Medication Administration During Power Outage
Penalty
Summary
The facility failed to implement its emergency plan for a planned power outage and did not accurately report the resulting unusual occurrence to the California Department of Public Health (CDPH). Despite being notified by the power company two weeks in advance, the Director of Maintenance only sent a text message to the management team, which was not the official communication method. As a result, key staff, including the Director of Nursing, Medical Records Director, and other managers, were not adequately prepared for the outage. On the day of the outage, staff were surprised by the loss of power and had to rely on paper Medication Administration Records (MARs), which were not available until after the power was restored. This led to delayed medication administration for 50 out of 111 residents. A resident and her family expressed concerns about the late administration of Parkinson's medication, which was particularly time-sensitive, and the resident was subsequently discharged with her family. Interviews with staff confirmed that the lack of timely communication and preparation resulted in the inability to administer medications as scheduled. The facility's report to CDPH did not accurately reflect the problems experienced during the outage, and the facility's policy required that unusual occurrences be reported accurately and completely.