Failure to Provide Timely Medication and Adequate Monitoring for Two Residents
Penalty
Summary
The facility failed to provide necessary care and services for two residents. For one resident, an error occurred during the admission process when the Admissions Director entered the dosage of an IV antibiotic incorrectly into the pharmacy system, using milligrams instead of grams. This mistake prevented the pharmacy system from flagging the medication as expensive, delaying the identification of the need for special compounding and shipment. As a result, the resident missed five doses of the antibiotic between admission and transfer back to the hospital, where treatment was continued. For another resident, documentation and monitoring were inadequate during an episode of epistaxis (nosebleed). The resident, who was on antiplatelet medications (Ticagrelor and Aspirin), experienced a nosebleed late in the evening. The nurse instructed the resident on first aid and notified the DON and physician, but did not document ongoing observations throughout the night. Certified Nursing Assistants reported significant bleeding, requiring multiple changes of towels, clothing, and cleaning of the resident's environment. The resident became lethargic and was later transferred to the hospital with low blood pressure. The lack of thorough monitoring and documentation contributed to the deficiency in care.