Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for one resident. The resident, who had diagnoses including chronic diastolic congestive heart failure, Type 2 diabetes mellitus with diabetic polyneuropathy, and intervertebral disc degeneration, was cognitively intact and had physician orders for pregabalin 200mg twice daily for neuropathy and tramadol HCL 50mg every six hours as needed for pain. Review of medication administration records and controlled medication declining sheets revealed multiple instances where pregabalin was not administered as scheduled, despite being documented as given on the Medication Administration Record (MAR). Staff interviews confirmed that the medication was not actually administered on those occasions, and the Director of Nursing (DON) and other staff acknowledged that discrepancies between the MAR and controlled medication sheets, along with correct narcotic counts, indicated the medication had not been given. Additionally, the resident received incorrect doses of tramadol HCL on several occasions. Although the physician's order specified 50mg, the controlled medication declining sheets and staff interviews confirmed that 75mg doses were administered multiple times. Several nurses and medication aides stated that they administered the 75mg dose because that was what was available in the blister pack, and they did not verify the correct dose against the physician's order. The DON confirmed that the blister packs contained 75mg tablets, not the ordered 50mg dose. Both the Medical Director and the facility Administrator stated that they expected medications to be administered as ordered and for documentation to be accurate and honest. The Medical Director specifically noted that missing doses of pregabalin could cause increased pain or discomfort for the resident. The deficiency was identified through review of records, interviews with staff, and direct confirmation of medication administration errors and documentation inaccuracies.