Failure to Account for and Administer Medications as Ordered
Penalty
Summary
The facility failed to properly account for and administer medications as ordered by physicians for two residents. For one resident with a history of bilateral leg amputations, neuropathy, and significant pain, the facility did not account for a full delivery of Dilaudid 4 mg tablets. Pharmacy records and delivery sheets confirmed that 120 tablets were delivered in two bubble packs, but only one bubble pack and one Controlled Medication Count Sheet (CMCS) were present and accounted for. Staff interviews revealed confusion and lack of verification regarding the number of bubble packs and the corresponding CMCS, with some staff only checking the quantity upon initial receipt and not during subsequent shift counts. The Director of Nursing confirmed that staff were not consistently verifying the total quantity received and remaining, as required by facility policy, which led to a missing bubble pack and incomplete documentation. For another resident with severe cognitive impairment, dementia, and psychosis, the facility failed to administer Alprazolam 0.25 mg as ordered by the physician. The medication was given 55 minutes earlier than prescribed, and this administration was not documented in the Medication Administration Record (MAR), although it was recorded on the CMCS. The resident's care plan required anti-anxiety medications to be administered as ordered, with monitoring for side effects and effectiveness. Staff interviews and record reviews confirmed the discrepancy between the CMCS and the MAR, and the Director of Nursing acknowledged that the failure to document the administration in the MAR was a violation of facility policy. Observations and interviews with nursing staff indicated inconsistent practices in medication counting, documentation, and verification. Staff often focused on the number of medications left rather than the total quantity received, leading to discrepancies and missing medications. Facility policies required reconciliation of controlled substances upon receipt, administration, and at each shift change, but these procedures were not consistently followed. The deficiencies resulted in a lack of accountability for controlled substances and improper administration and documentation of medications.