Failure to Provide Timely Treatment and Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs in two separate instances. In the first case, a resident with Alzheimer's disease and dementia, who lacked medical decision-making capacity, experienced a fall that was witnessed and reported by both a CNA and the resident's alert and oriented roommate. Despite this, there was no documentation of the fall in the resident's medical record, and no neuro-checks, treatment, or follow-up were performed at the time of the incident. The nurse on duty at the time did not document or address the fall, and subsequently resigned without providing a statement regarding the incident. In the second case, another resident did not receive multiple physician-ordered medications and treatments in a timely manner over the course of November and December. Missed orders included administration of medications via PEG tube for conditions such as seizures, GERD, and hyponatremia, as well as essential care tasks like tracheostomy care, skin care, repositioning, and enteral feeding management. These omissions were confirmed through a Medication Administration Audit Report and acknowledged by the facility administrator as unacceptable. Both deficiencies were identified during the survey process as random opportunities for discovery and had the potential to affect more than a minimal number of residents. The failures involved lack of documentation, failure to follow physician orders, and lack of timely care and treatment for residents with complex medical needs.