Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure proper medication administration and documentation for four residents, resulting in multiple deficiencies. For one resident with a history of hip dislocation and pain, the prescribed 4% Lidocaine patch was not available on a documented date, and the Medication Administration Record (MAR) was marked as unavailable. Staff interviews confirmed that the facility sometimes had to purchase patches from a drug store due to supply issues, but the patch was not always on hand. Another resident with diabetes did not consistently receive prescribed Glargine insulin, as evidenced by a blank entry on the MAR and the resident's report of inconsistent administration and poor blood sugar control. A third resident, with diagnoses including cataracts and neuropathy, did not have a prescribed Lidocaine patch transcribed onto the MAR, and administration of prescribed Latanoprost eye drops was not documented on the MAR. The resident reported not receiving the eye drops and being told by staff that the medication was not available. For a fourth resident with dementia and palliative care needs, there was confusion regarding the form and dosage of Hydromorphone, with staff unsure whether the medication should be administered as a tablet or liquid, and the physician order specifying a tablet but the dosage written in milliliters. Facility policy requires that all medications and treatments be administered and documented as ordered, but these requirements were not met in these cases.