Failure to Administer Medications Timely and Inadequate Emergency Response for Hypoglycemia
Penalty
Summary
The facility failed to follow its own policies and procedures regarding medication administration, documentation, and emergency response for multiple residents. Specifically, three residents did not receive their prescribed medications in a timely manner, and medication administration was not properly documented. Observations revealed that medications scheduled for specific times were administered late, and staff did not consistently sign out medications as they were given. The electronic medication administration record (EMAR) showed multiple residents highlighted as overdue for medication, and staff admitted to delays and incomplete documentation due to being busy or unfamiliar with procedures. A critical incident involved a resident with multiple complex medical conditions, including diabetes, chronic respiratory failure, and a history of uncontrolled diabetic status. This resident was found unresponsive with a critically low blood sugar level. Nursing staff attempted to administer oral sugar to the unresponsive resident, which is not a safe or effective intervention, and were unable to obtain intravenous access for dextrose. Glucagon, which was available in the emergency kit per facility policy, was not administered. Emergency medical services were called, but there was a delay in both the response and the appropriate intervention for hypoglycemia. The resident was subsequently hospitalized in the ICU for severe hypoglycemia, sepsis, and multiple infections, with documentation from the hospital noting poor hygiene, extensive skin breakdown, and concerns of neglect. Interviews with staff and review of facility policies confirmed that the required protocols for hypoglycemia and change in condition were not followed. Staff acknowledged that oral administration of sugar to an unresponsive resident was inappropriate and that glucagon should have been administered. There was also a failure to change the resident's Foley catheter as required, contributing to infection risk. The facility's own policies mandate timely medication administration, proper documentation, immediate emergency response, and adherence to hypoglycemia protocols, all of which were not met in these instances.