Failure to Administer Medication as Scheduled and Inadequate Documentation
Penalty
Summary
The facility failed to ensure that medications were administered as scheduled per physician orders for one resident. Specifically, the resident reported not receiving his prescribed Amlodipine at the scheduled morning time on multiple occasions within a twenty-day period, sometimes receiving it as late as the evening. Review of the Medication Administration Audit Report confirmed several instances where the medication was administered late, including times in the afternoon and evening, and one instance where there was no documentation of administration at all. Progress notes did not provide explanations for the late administration or indicate that the physician was notified, as required by facility policy. Interviews with nursing staff revealed inconsistent practices regarding documentation and notification when medications were not administered as ordered or were refused by the resident. One LPN could not recall if the medication was given or refused and admitted to not documenting the event. The Director of Nursing stated that medications should be administered within a specific time window and that late administration or refusals should be communicated to the physician and documented. The resident in question had diagnoses of essential hypertension and atherosclerotic heart disease and was cognitively intact at the time of the deficiency.