Failure to Administer Medications as Ordered for Two Residents
Penalty
Summary
The facility failed to administer medications according to physician orders for two of three residents reviewed for medication administration. Facility policy requires medications to be administered as prescribed and within 60 minutes of scheduled times, with documentation on the Medication Administration Record (MAR). For one resident, multiple medications including Amiloride, Celexa, Cranberry tablets, Fiber-Lax, and Famotidine were not administered on several specified dates, as evidenced by gaps in the MAR. The resident, who was documented as cognitively intact, reported that missed doses typically occurred in the evening and often involved agency nurses unfamiliar to her. For another resident, the MAR showed that several daily medications, such as Aspirin, CoQ-10, Multivitamin, Fenofibrate, Rosuvastatin, and Myrbetriq, were not administered on multiple dates. The Director of Nursing was unable to provide an explanation for the missed doses and acknowledged that if medications were not documented as given, they were not administered. The Director also stated that medications are expected to be given as ordered and recognized that failure to do so can be harmful to residents.