Medication Administration and Controlled Substance Documentation Deficiencies
Penalty
Summary
The facility failed to ensure safe medication administration and accurate accountability of controlled medications for four residents. For one resident with hypertension and dependence on a ventilator, blood pressure medication (Amlodipine) was administered late on six occasions, and the physician was not notified of the delays. Additionally, the nurse did not check the resident's blood pressure immediately prior to administering the medication, as required by the physician's order. The facility's policy required medications to be administered within one hour of the scheduled time and for vital signs to be checked if necessary, but these procedures were not followed. For the same resident, there was a discrepancy between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR) for a dose of Oxycodone/APAP, a controlled medication. The CDR indicated a dose was removed and administered, but the MAR lacked documentation of administration and pain assessment. The nurse responsible did not document the administration or the resident's pain level, contrary to facility policy, which requires immediate documentation of all medications administered, including PRN effectiveness. Another resident with epilepsy and anoxic brain damage had discrepancies in the documentation and administration of Ativan, a controlled medication. The CDR, MAR, physician's order, and pharmacy label did not match, and the inventory of the medication was inconsistent. The resident was not reassessed for effectiveness of PRN Ativan within the required 30 minutes, and the physician's order lacked a maximum dose and clear instructions for when to notify the physician. Additionally, two residents with diabetes received insulin injections in the same sites repeatedly, without proper rotation, despite care plans and facility policy requiring site rotation to prevent complications.