Failure to Administer and Document Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring that Acidophilus, a prescribed supplement, was administered as ordered on multiple occasions. Specifically, the medication was not given on several documented dates and times, as evidenced by gaps in the Medication Administration Record (MAR). Interviews with staff confirmed that if a medication is not documented as given in the MAR, it is considered not administered. The staff responsible for administering and documenting the medication did not record its administration, and attempts to interview the medication aide responsible were unsuccessful. The resident involved was an adult male with a history of diabetes mellitus with diabetic arthropathy, cognitive communication deficit, and a need for assistance with personal care. His care plan included interventions for pain management and required medications to be administered as ordered. The facility's policy required medications to be administered and documented in a timely manner, with oversight by nursing leadership. Review of the MAR and staff interviews confirmed that the required documentation and administration did not occur for the specified dates and times.