Failure to Ensure Accurate Medication Administration and Proper Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for multiple residents. In several instances, medications were not administered according to physician orders. For example, one resident received a lower dose of docusate sodium than prescribed, and another was nearly given expired medication, which was only prevented by surveyor intervention. Additionally, medications were administered outside the required time frames, with some residents receiving their scheduled morning medications significantly late, and without proper documentation or physician notification regarding the delay. The facility also failed to maintain proper medication disposal practices. The Discarded Medication Log was incomplete, lacking required dates, signatures, and witness documentation for numerous medications belonging to several residents. Unlabeled and expired medications, such as meropenem vials, were found stored in the medication cart after the prescribed course was completed, contrary to facility policy. These lapses were confirmed through interviews with nursing staff and the DON, who acknowledged that the required procedures for medication destruction and documentation were not followed. Furthermore, medication administration practices were not consistently supervised. In one case, a nurse left multiple medications at a resident's bedside for self-administration, despite the resident not being assessed or authorized for self-administration. The medications were taken late, outside the scheduled administration window, and without staff observation, which was contrary to both physician orders and facility policy. These deficiencies were identified through direct observation, record review, and staff interviews, all of which confirmed that established protocols for medication administration and documentation were not adhered to.