Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice for three residents. One resident was prescribed pantoprazole to be administered before breakfast at 6:30 A.M., but the medication was left at the bedside, allowing the resident to self-administer it at the wrong time and without supervision. The resident did not have an order to self-administer medications, and the nurse on duty confirmed that the medication was not given as ordered. The Director of Nursing (DON) acknowledged that medications should not be left at the bedside and that staff are expected to remain with residents until medications are taken. Another resident was administered Advair Diskus, an inhaled steroid, without following the manufacturer's instructions. The nurse failed to instruct the resident to rinse and spit out water after inhalation, as required to prevent oral thrush. The DON confirmed that the manufacturer's instructions were not followed during administration and that this step is necessary to reduce the risk of developing a fungal infection in the mouth or throat. For a third resident, the facility could not account for two doses of a controlled medication, hydrocodone-APAP, which were removed from the locked supply but not documented on the medication administration record (MAR). The nurse and DON both stated that controlled medications must be signed out and documented when administered, but this was not done. Additionally, the DON reported that required weekly audits of controlled medications were not being conducted as per facility protocol.