Failure to Administer Scheduled Medications
Penalty
Summary
The facility failed to ensure that medications were administered to multiple residents, including four sampled residents and ten unsampled residents, on the evening of February 25, 2025. Observations and record reviews revealed that medications scheduled for 5:00 PM were not administered to residents, including critical medications such as Xarelto for deep vein thrombosis/pulmonary embolism and insulin for diabetes management. The Medication Administration Records (MAR) for these residents were not signed, indicating that the medications were not given, and there was no documentation of medication refusal. Interviews with facility staff revealed a breakdown in the medication administration process. Licensed Practical Nurse (LPN) H, who was responsible for administering medications, left the facility at 4:00 PM, and the oncoming nurse, Registered Nurse P, did not administer the 5:00 PM medications. The facility's policy requires medications to be administered according to physician orders and documented in the MAR, but this was not followed. Additionally, the facility did not conduct audits or reviews of medication administration records to monitor compliance, contributing to the oversight.
Plan Of Correction
F760 Residents are Free of Significant Med Errors Element 1: Residents #702 and #705 continue to reside within the facility. An audit was conducted to ensure both residents have been receiving their medications per physician orders. Resident #703 and #704 no longer resides in the facility. Element 2: Like residents were identified as residents who reside in the facility. Like residents have been audited to ensure their medications have been being administered per the physician orders. Element 3: The procedure to implement the plan of correction included: 1. IDT reviewed F760. 2. IDT reviewed the Medication Administration policy and deemed appropriate. 3. RN/LPN were re-educated on the Medication Administration policy on ensuring medications are always administered. Element 4: The process to ensure that the specific citation remains corrected includes: 1. The Director of Nursing / Designee will audit 10 residents weekly to ensure medication are signed out and administered. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. 2. The Administrator will be responsible for sustained compliance.