Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure proper pharmaceutical services and medication administration for three residents, as evidenced by direct observations, interviews, and medical record reviews. For one resident, the facility did not accurately document, sign out, or dispose of a narcotic medication (tramadol) according to its own policies and procedures. The medication administration record (MAR) and the controlled drug record did not match, and there was an unidentified, undated, and unlabeled tablet found attached to the narcotic bubble packet. Staff interviews confirmed that the required documentation and proper disposal procedures, including dual signatures for wasting narcotics, were not followed. Another resident with a physician's order for docusate sodium to be held in the presence of loose stool was administered the medication without the nurse assessing for current episodes of loose stool or diarrhea. Medical records showed the resident had a recent history of loose stool, and the nurse acknowledged not checking for this condition prior to administration. The DON confirmed that the medication should have been held as per the physician's order when loose stool was present. A third resident had a physician's order for losartan potassium to be held if the systolic blood pressure (SBP) was below 130 mmHg. Despite this, the MAR showed the medication was administered on multiple occasions when the resident's SBP was below the specified threshold. Both the nurse and the DON verified that the medication was given contrary to the physician's order, and the documentation supported this finding.