State Findings:
On 6/25/21 an order was written for [MEDICATION(S)], a hormone associated therapy and hormone based [CONDITION(S)] used to treat prostate cancer. The order read:
Give 4 tablet by mouth one time a day for prostate cancer take 4 x 250mg tabs = 1000mg dose
Give on an empty stomach, one hour before eating or two hours after eating.
The order was scheduled to be given daily at 6:00 a.m.
A facility investigation was started on 9/21/21 after the former nursing home administrator was contacted by Resident #4’s oncology nurse practitioner inquiring whether or not he was receiving the ordered medication.
After consulting with the pharmacy and the VA there was no evidence that this medication was ever received.
The investigation revealed that during the time between 6/25/21 and 9/21/21, there were a total of three nurses that documented the medication was given and nine other nurses documented the medication was not given and the appropriate parties, nursing supervisor, physician, pharmacy and responsible party, were not notified.
The nurses who were found to have documented the medication as given were suspended pending the investigation and ultimately terminated from their positions.
On 9/22/21 all facility nurses were suspended and agency nurses were brought in until facility nursing staff received education related to medication administration, documentation, procedures for unavailable medications, and all pharmacy procedures related to ordering and verifying medications were received.
The DON was interviewed on 11/17/21 at 10:54 a.m. She stated the nurses who were involved in the
situation were not following the medication administration policies and did not follow professional standards of nursing and learning of the situation was disappointing. She stated nurses should only document a medication as administered after the nurse ensured the medication was given. She stated the nurses who signed that the medication was unavailable should have called the pharmacy and physician each time and documented the efforts to obtain the medication. She stated a resident not receiving an ordered medication for three months was an error.
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NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
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Personal Note from NHA-Advocates
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