Failure to Follow Medication Administration Policies and Procedures
Penalty
Summary
The facility failed to ensure that licensed nurses followed their policies and procedures for medication administration for three residents. For one resident with a history of cancer and dry mouth, the ordered Biotene medication was not available, resulting in missed doses over two days. Documentation showed that the medication was not administered, and there was incomplete progress note documentation explaining the missed doses. Although the facility's policy required notifying the physician when medications were unavailable, this was not consistently done, as confirmed by staff interviews and review of the medical record. Another resident, admitted with a urinary tract infection and ESBL resistance, had a physician's order for intravenous Ertapenem. The medication administration record (MAR) lacked documentation for four specific dates, and staff confirmed there was no evidence the medication was administered as ordered. The DON verified the missing documentation and acknowledged that what was not documented was considered not done, emphasizing the requirement for immediate documentation after medication administration. A third resident with an enteral feeding tube and a diagnosis of dysphagia was observed receiving all medications via gastrostomy tube (GT), despite physician orders specifying oral administration. The MAR reflected that medications were signed as given orally, not via GT, and staff confirmed that the orders should have accurately reflected the actual route of administration. The discrepancies between the physician's orders, the MAR, and the actual administration route were acknowledged by nursing staff and facility leadership.