Failure to Provide Timely and Accurate Medication Administration for New Admissions
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for four newly admitted residents. In multiple instances, prescribed medications such as Latanoprost, Rosuvastatin, Trazodone, Triamcinolone, Clarithromycin, Amitriptyline, Aspirin, Metoprolol, Levofloxacin, and Atorvastatin were not given because they were not available at the time of administration. Facility policy required that medications be transcribed accurately and administered as ordered, and that backup medication supplies be checked and pharmacy, physician, and family be notified if medications were unavailable. However, these steps were not consistently followed. For each affected resident, there was a lack of documentation indicating that the pharmacy or physician had been notified about the unavailability of medications or missed doses. Nursing staff acknowledged that they did not always follow up with the pharmacy or physician, and in some cases, they were unsure if they had taken any action regarding the missed medications. Additionally, there was no evidence that medications were obtained from the backup supply when unavailable, and required documentation in nursing notes was missing. One resident's hospital discharge order for Levofloxacin was incorrectly transcribed, resulting in the medication being scheduled at the wrong interval. The Director of Nursing confirmed that the backup medication safe was not used to obtain the missing medications and that required notifications and documentation were not completed. These failures resulted in residents not receiving their prescribed medications as ordered upon admission.