Medication Administration Errors and Failure to Follow Protocols
Penalty
Summary
Surveyors identified multiple deficiencies related to medication administration for several residents. One resident receiving insulin (liraglutide/Victoza) did not have injection sites rotated as required by standards of practice and the manufacturer's guidelines. Documentation showed repeated use of the same injection sites over several months, and nursing staff confirmed that site rotation was not performed. This failure was acknowledged by both nursing staff and facility leadership, who stated that not rotating sites can affect medication absorption and is not in accordance with accepted practice. Two other residents were found to have received scheduled oral medications outside of the prescribed administration window. Nursing staff administered medications earlier than the scheduled time, citing resident preference and convenience, but did not document provider approval or the reason for the deviation. Facility policy and interviews with pharmacy and nursing leadership confirmed that medications should be given within a one-hour window before or after the scheduled time, and any deviations should be communicated to and approved by the provider, with documentation in the medical record. The electronic medication administration record (eMAR) system did not allow documentation of the actual administration time outside the allowed window, and staff reported giving medications early on multiple occasions without proper documentation or provider notification. Additionally, a resident receiving medications via gastrostomy tube (g-tube) did not have water flushes administered between medications, contrary to facility policy and standard practice. The nurse administered all medications consecutively, flushing only before and after the medication pass, and stated that she followed the physician's order, which did not specify flushing between medications. Facility policy, as well as statements from nursing and pharmacy leadership, required flushing with water between each medication to prevent mixing and ensure tube patency. The nurse also did not consistently check tube placement and patency as required by policy.