Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered in accordance with the prescriber's order or professional standards for three residents. Resident #1, who has a seizure disorder, was administered Depakote Sprinkles outside the regulated time frame on multiple occasions in October and November 2024. There was no documented evidence that the physician was informed of these late administrations. Licensed Practical Nurses involved admitted to errors in documentation and timing but did not notify the physician as required. Resident #2, diagnosed with Parkinson's disease, received Carbidopa-Levodopa outside the regulated time frame on several occasions in August and September 2024. The medication administration record showed discrepancies in the timing of doses, and the involved LPNs did not notify the physician of the late administrations. Some LPNs claimed to have administered the medication on time but signed the records late due to system glitches or being short-staffed. Resident #3, who suffers from insomnia, refused Trazodone and Melatonin on multiple occasions in January 2024, and there was no evidence that the physician was informed of these refusals. Additionally, there was a lack of documentation for the administration of these medications on one occasion. The Director of Nursing acknowledged the need for proper documentation and physician notification when medications are administered late or refused.
Plan Of Correction
Plan of Correction: Approved January 29, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F760- Plan for affected Residents: Residents #1 & #2 will have their medication given within the regulated time frame. Resident #3 MD/NP will be made aware when the resident refuses medication. Resident #1 [MEDICATION NAME] and [MEDICATION NAME] levels were drawn, and the levels were in normal limits with no adverse effects. Plan to identify other potentially affected residents: Each Nurse Manager will do a weekly audit on 10 residents on their unit to ensure the medication is being administered timely. In addition, the Nurse Manager will conduct weekly chart audits on medication administration documentation to ensure that MD was made aware if a resident refused medication. Plan for system changes and measures to prevent occurrences: The policy was reviewed. Nurse Educator/ADON will re-educate LPN/RN’s on medication administration policy highlighting medication administration time. MD/NP to be notified when a resident refuses medication and this should be documented in the progress note as well as the medication administration record. Weekly medication administration competency will be done on 10% of the licensed nurses by Nurse educator/designee. Plan for Monitoring Corrective action: Nurse managers will conduct weekly audits on 10% of the residents on their unit to ensure that medications are given at the time prescriber ordered or in accordance with professional standards. Additionally, weekly chart audits will be done by each nurse manager on 10% of residents on their unit to ensure that for those residents that refused medication the NP/MD was notified, and it’s documented in the medical record. The facility plans to monitor its performance to ensure solutions are sustained by nurse educator/designee conducting weekly medication administration competency on 10% of the licensed nurses. Findings will be reported to the QAPI committee monthly times three (3) and quarterly times two (2).