Failure to Document Insulin Injection Sites and Crush Medications Without Physician Order
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents by not ensuring proper medication administration and documentation. For one resident with moderate cognitive impairment and diabetes, the facility did not document the injection sites for multiple insulin orders, including Lantus Solostar and Novolog Flexpen, as required by facility policy. The Medication Administration Record (MAR) for the month reviewed did not show any documentation of injection sites for these insulin medications, and both the Director of Nursing (DON) and a registered nurse confirmed the absence of this documentation. The facility's policy required recording the injection site for medications administered by injection, but this was not followed. In a separate incident, another resident with moderate cognitive impairment was observed receiving crushed oral medications without a physician's order to do so. During a medication administration observation, a licensed vocational nurse (LVN) crushed and administered several oral medications to the resident, despite the resident's medical record lacking any physician's order permitting the medications to be crushed. The LVN confirmed that the medications were crushed based on the resident's preference, not on a physician's directive. The DON and the pharmacy consultant both acknowledged that crushing medications should require a physician's order, but this was not obtained in this case. These failures were identified through observation, interviews, and review of medical records and facility policies. The lack of documentation for insulin injection sites and the administration of crushed medications without a physician's order were both contrary to the facility's established policies and procedures, as well as standard pharmaceutical practices.