Deficient Medication Administration and Documentation Practices
Penalty
Summary
The facility failed to ensure accurate documentation and proper handling of medication administration, particularly with controlled substances, affecting seven residents. In several instances, documentation on controlled substance accountability sheets was inaccurate, including incorrect recording of dates, times, amounts administered, and quantities remaining. For example, one resident's records showed inconsistencies in the number of tablets dispensed and remaining, and it was unclear whether medications were removed from the medication cart or the electronic dispensing system. Registered nurses involved confirmed the documentation errors during interviews. There were also failures in following physician orders and proper medication administration protocols. One nurse removed multiple residents' as-needed controlled medications from the electronic dispensing system at the same time, intending to administer them later during her shift, rather than as needed. Another resident received oxycodone earlier than prescribed, with insufficient documentation to confirm the timing and administration of the dose. Additionally, a nurse administered liquid morphine to a resident without a physician order, and the source of the medication was unclear. In another case, documentation indicated a resident received Ativan, but the medication was actually administered to a different resident, resulting in inaccurate clinical records. The facility's medication administration policy required strict adherence to the five rights of medication administration and proper documentation immediately after administration. However, the findings revealed multiple deviations from these protocols, including administering medications without orders, removing as-needed medications in advance of need, and failing to document administration accurately. These actions and inactions led to the cited deficiencies in pharmaceutical services and medication management.