Medication Administration and Pharmaceutical Service Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies in the administration of pharmaceutical services and medication management for several residents. One incident involved a nurse administering mupirocin ointment to a resident with a stage two sacral pressure injury without a current physician's order. The nurse had continued to apply the discontinued medication, which remained in the treatment cart, for several days, believing there was still an active order. Both the nurse and other staff acknowledged that the medication should have been removed from the cart after discontinuation, and that medication administration should always be based on an active physician's order, as per facility policy. In another instance, two residents did not receive their scheduled medications at the prescribed times. A nurse administered medications earlier than the scheduled time, outside the one-hour window allowed by facility policy, due to the residents' preferences and convenience. The nurse did not document the reason for the early administration or obtain a revised order from the provider to reflect the change in timing. The facility's electronic medication administration record (eMAR) system also did not allow documentation of the actual time of administration outside the scheduled window, leading to further deviation from policy. Additionally, a nurse failed to follow proper procedures for administering medications via a gastrostomy tube for another resident. The nurse did not check the tube's placement and patency before administering medications and did not flush the tube with water between medications. These actions were not in accordance with the facility's medication administration policies and procedures, which require verification of tube placement and flushing to ensure safe and effective medication delivery.