Medication Administration and Management Deficiencies
Penalty
Summary
The facility failed to maintain professional standards of practice by not administering medications in a timely manner according to physician orders for a resident. During an initial tour, it was observed that a resident received their scheduled medications late. The resident had a history of chronic pain syndrome, anxiety disorder, bipolar disorder, and adult failure to thrive. The review of the Medication Admin Audit Report revealed multiple instances where medications such as morphine sulfate, methadone HCL, and lorazepam were administered outside the prescribed time frames. The Director of Nursing acknowledged that medications given outside the one-hour window before or after the scheduled time were considered late, and emphasized the importance of timely administration to prevent potential overdose. Additionally, the facility failed to ensure proper medication management by borrowing medications from one resident's supply to administer to another. During medication administration observations, an LPN was seen borrowing medications from other residents when the required medications were not available in the medication cart. This occurred for two residents, where medications such as escitalopram oxalate and metformin HCL were borrowed from other residents' supplies. The LPN admitted to the surveyor that borrowing medications was against protocol, but justified the action due to the lack of backup medications in the cart. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the proper procedure when a medication is unavailable is to check the pyxis for backup, notify the physician, and contact the pharmacy for a STAT order if necessary. Both emphasized that medications should not be borrowed from one resident for another, as it could lead to the original resident running out of their prescribed medication. The facility's Medication Administration policy also outlined the requirement to administer medications within a specific time frame and to verify medication details before administration.
Plan Of Correction
1. Residents affected by the deficient practice: The facility failed to maintain professional standard of practice by ensuring medications were administered in a timely manner in accordance with the resident's physicians order and ensuring proper medication management by borrowing medications from one resident supply to administer to another resident. Resident #48 had not had further cited concerns of receiving medications outside of parameters since [R] Resident #60 and Resident #4 received medication as ordered. Licensed nurse who administered medication as cited to resident #60 and #4 received individual education. 2. Identifying other residents who could be affected by the deficient practice: All residents can be affected by this practice. Residents #48, #60, and #4 were audited for medication administration outside of parameters with no further issues identified. Five other residents were audited to ensure that all medications were available with no issues identified. 3. Measures or systemic changes to ensure that the deficiencies will not recur: Licensed nurses in-serviced on the Medication Administration Policy and the process if a resident is out of their supply of medication beginning 12/5/24 by Assistant Director of Nursing. 4. Monitoring the continued effectiveness of the systemic change: The Unit Managers/Designee will conduct an audit of medication availability and administration time parameters for five residents weekly x 4 then monthly x 2. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.