Failure to Reevaluate Pain Medication, Complete Lab Orders, and Monitor Fluid Status
Penalty
Summary
The facility failed to provide necessary treatment and care services for a resident with severe cognitive impairment and multiple medical diagnoses, including non-Alzheimer's dementia and malnutrition. The resident was routinely administered acetaminophen twice daily for pain management, despite documentation over several months indicating no complaints of pain and regular pain assessments showing no pain. The care plan required reassessment of the need for pain medication, but this was not done, and the medication regimen continued without reevaluation, contrary to facility policy and professional standards. Additionally, the facility did not carry out physician-ordered diagnostic laboratory tests, including blood work, for the resident. The Director of Nursing confirmed that the laboratory tests ordered by the physician were not performed. The resident's care plan also required monitoring and documentation of fluid intake and output due to a risk for fluid deficit related to chronic urinary tract infection. However, daily fluid intake was not consistently tallied, output was not recorded, and the resident's intake was frequently below the minimum required amount, with no documentation to show that intake and output were monitored as required by the care plan and facility policy. When the resident experienced a change in condition, including abdominal pain and other symptoms, a STAT order for a urinalysis via straight catheterization was received. The nurse attempted to obtain the specimen twice without success but did not notify the physician of the failed attempts or document the order and actions taken. The STAT order was endorsed to the next shift without timely follow-up, and the Director of Nursing was unaware of the delay. The facility's policies required prompt communication with the physician and documentation of such events, which did not occur in this case.