Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that significant medications were administered as ordered by the physician for a resident. The facility's policy on medication administration, dated May 23, 2024, requires that medications and biologicals be administered by the same licensed nurse who prepared the dose and that they be given as soon as possible after preparation. However, a review of the clinical record for a resident admitted on November 22, 2024, with diagnoses including atrial fibrillation, hypertension, and macular degeneration, revealed that the resident did not receive their prescribed medication, Synthroid, on four separate occasions. The resident's physician orders dated November 23, 2024, indicated that the resident was to receive Synthroid orally once a day. The Medication Administration Record (MAR) showed that on December 29, 2024, December 30, 2024, January 21, 2025, and January 27, 2025, the medication was documented as unavailable and not given. During an interview on January 30, 2025, the Director of Nursing confirmed the facility's failure to administer the medication as ordered.
Plan Of Correction
Resident 50 medications arrived from pharmacy and administered per orders. All residents' medication cards were evaluated to ensure medications are available. Nursing staff will be educated by the Director of Nursing or designee on ensuring that medications are available and the need to reorder is completed timely, as well as physician notified when medication are not given. Night shift will check medication carts for need to reorder medication before quantity is low. Charge nurse will check daily if meds are not available or not received, with unit nurse, to ensure they are ordered and MD aware. Audits will be completed that nurses reorder medications timely and MD notification for medication not received. The Director of Nursing or a designee will audit for medications that quantity is sufficient weekly for a month, bi-weekly for a month, and monthly thereafter. All results will be reviewed at QAPI.