Failure to Ensure Proper Medication Administration and Timely Delivery
Penalty
Summary
The facility failed to ensure proper medication administration for six residents by not following best practices for medication preparation and administration, not administering medications at their scheduled times, and failing to ensure medication availability. For one resident with rheumatoid arthritis, a scheduled dose of Adalimumab was omitted due to lack of supply, and there was no timely notification to the pharmacy or physician. This resulted in the resident missing a dose and experiencing increased rigidity and pain, as documented in the resident's medical records and personal interview. For several residents with G-tubes, a nurse was observed crushing and mixing multiple medications together in one cup and administering them via G-tube without checking for tube placement or flushing between medications, contrary to facility policy and best practice. The nurse admitted to not following protocol due to being pressed for time after several staff called off, which led to late medication administration for multiple residents. The nurse also acknowledged awareness of the correct procedure but did not follow it due to workload pressures. Additionally, medications for several residents were not administered within the prescribed time frames, as required by physician orders and facility policy. The facility's own policies require medications to be administered within one hour of the scheduled time and for medication supplies to be ordered in advance to prevent omissions. Interviews with staff confirmed that these protocols were not followed, leading to missed and late doses for residents with complex medical needs, including those with epilepsy, hypertension, diabetes, and GERD.