Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the case of a resident who did not receive prescribed medications. The facility's policy on medication administration times, dated January 10, 2025, mandates that authorized personnel administer medications according to the times determined by the facility's pharmacy committee or physician/prescriber. However, a review of the clinical record for a resident admitted on January 26, 2025, revealed that the resident, who had diagnoses of osteoarthritis, diabetes mellitus, and hypertension, did not receive their prescribed medications, Metformin and Lisinopril-hydrochlorothiazide, as indicated by blank spaces in the medication administration record (MAR) for that day. Further investigation showed that the facility's Omni Inventory list, which includes emergency medications, contained both Metformin and Lisinopril. Despite this, there was no documentation in the clinical notes explaining why the medications were not administered or why the emergency medication was not accessed. An interview with the Director of Nursing confirmed the failure to administer the medications as ordered, resulting in a significant medication error for the resident.
Plan Of Correction
Resident R1 was affected by this deficient practice as there were two medications that were not given at the time they were due. All residents have the potential to be affected. To prevent this from recurring, re-education will be provided to licensed nursing staff regarding the medication administration time policy. Licensed Nurses will be re-educated on the importance of ensuring that medications are given according to orders by the DON/designee. Re-education will also be completed with licensed nurses regarding the importance of documenting indications as to why a medication would not be given. For ongoing compliance, the DON/designee will conduct audits of medication administration observations and documentation 2 times per week for 2 weeks, then weekly x 2 weeks. Sustained compliance will be monitored by the QAPI committee.