Failure to Administer Medications and Monitor Wound Care per Orders
Penalty
Summary
The facility failed to administer medications according to provider orders and did not properly monitor a surgical wound for a resident admitted with a hip fracture and fibromyalgia. Medication administration records showed that Tramadol was not given on several occasions due to the facility not obtaining the medication from the pharmacy, and Oxycodone supplies also ran out, requiring emergency orders. Progress notes and interviews confirmed that the resident experienced significant pain on days when medications were missed, and both the resident and a family member reported multiple instances of being without pain medication. Staff interviews revealed lapses in medication reordering and administration, with admissions that medications were sometimes missed or late due to ordering issues. Additionally, after a change in wound care orders to a honeycomb dressing, there were no instructions for ongoing wound monitoring, and staff did not implement further wound observations or treatments. The resident subsequently developed signs of infection, including fever, chills, and wound redness, and was sent to the emergency department for treatment. Staff interviews indicated that wound care monitoring was expected but not consistently performed, and multiple attempts to reach the wound care nurse were unsuccessful.