Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to ensure the accurate administration of medications for three residents. One resident with diabetes and end-stage renal disease self-administered Tresiba insulin without a physician's order or a self-administration assessment, and there was no care plan in place for self-administration. Additionally, a significant quantity of the resident's insulin was unaccounted for, and staff allegedly borrowed insulin from another resident's supply for administration, contrary to facility policy and safe medication practices. Another resident with multiple chronic conditions, including COPD, pulmonary embolus, and chronic pain, did not receive several doses of prescribed medications, including controlled substances and pain medications. The resident reported frequently having to request missing medications, and the medical record lacked documentation explaining whether the medications were administered, refused, or unavailable. The facility's medication administration policy was not followed, as staff failed to document missed doses or provide required progress notes. A third resident with moderate cognitive impairment and multiple serious diagnoses, including cirrhosis and chronic kidney disease, did not receive a scheduled Epoetin Alfa injection as ordered. The medication was withheld due to a missing hemoglobin level, but there was no order obtained for the necessary lab work, and the omission was not properly documented. These deficiencies were identified through observation, staff and resident interviews, and record review, and they demonstrate failures in medication administration, documentation, and adherence to facility policy.