Failure to Properly Store, Document, and Timely Administer Medications
Penalty
Summary
The facility failed to ensure that medications for several residents were properly stored, documented, and administered according to physician orders and facility policy. One resident, who had a history of psoriatic arthritis mutilans, muscle weakness, and major depressive disorder, was found to be keeping all her medications at her bedside, including a lidocaine patch that was not ordered by a physician or documented in her records. This resident reported that her family supplied her medications, and she would mix pills from old and new bottles, leading to concerns about medication expiration and proper documentation. The nurse confirmed awareness of the resident's self-stored lidocaine patch but stated she had not administered it, and there was no physician order for its use. Additionally, the facility did not administer medications in a timely manner as ordered by physicians for three residents. Medication Administration Audit Reports showed that medications scheduled for administration at 9 a.m. were repeatedly given late, sometimes several hours past the scheduled time. Residents reported that their morning medications were often administered late, and one resident stated that requests to receive medications on time were not consistently honored by nursing staff. These delays were observed across multiple days and affected residents with various medical conditions, including diabetes, epilepsy, asthma, and anxiety disorder. Interviews with staff, including the Director of Nursing, revealed that all medications kept by residents should be documented and have corresponding physician orders. The DON acknowledged that undocumented use of medications, such as the lidocaine patch, could result in unassessed pain and that mixing medications from different bottles could obscure expiration dates. Facility policy required medications to be administered within one hour of the prescribed time and for all medications to be checked for expiration prior to administration, but these procedures were not followed in the cases reviewed.