Failure to Administer Medications as Ordered and Provide Appropriate Supplies
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for two residents. For one resident with diagnoses including nontraumatic intracerebral hemorrhage, diabetes mellitus type 2, and glaucoma, medications were not administered at the times ordered by the physician. Specifically, eye drops prescribed for glaucoma were given several hours after the scheduled administration times on multiple occasions. The facility's own policies required medications to be administered as ordered, and the Director of Nursing confirmed that these delays constituted a treatment delay and a medication administration error. Additionally, the same resident, who was frequently incontinent and required maximal assistance, was not provided with the correct size of incontinent briefs as requested. The resident reported discomfort and was told by staff that the appropriate size was not available, leading the resident's family member to bring personal supplies. Facility documentation confirmed that the correct size was not available at the time of need, and the Director of Nursing acknowledged that care supplies should be readily available to prevent discomfort and potential complications. For another resident with cellulitis, bladder cancer, and heart failure, the facility failed to notify the physician when the resident did not have a peripheral IV catheter in place, resulting in missed doses of prescribed intravenous antibiotics. Progress notes and medication administration records showed that the resident went without IV access and missed scheduled doses, with no documentation of physician notification. The Infection Preventionist and Director of Nursing both confirmed that the lack of notification and missed medication doses disrupted antibiotic therapy, as outlined in facility policy.