Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for two of three residents reviewed for significant medication errors. According to the facility's policy, medications are to be administered within 60 minutes of scheduled times and documented on the Medication Administration Record (MAR). For one resident with diagnoses including epilepsy, hypertension, and venous thrombosis, multiple prescribed medications such as Keppra, Oxcarbazepine, Chlorthalidone, Eliquis, and Amlodipine were not administered on several occasions as documented in the MAR. The resident reported that missed doses often occurred when agency nurses were on duty. Another resident with diagnoses of diabetes, ocular hypertension, primary hypertension, peripheral vascular disease, and heart disease also experienced missed doses of several critical medications, including Clopidogrel, Glimepiride, Hydrochlorothiazide, Lisinopril, Metoprolol Succinate, Metformin, Cephalexin, and Pregabaline, as recorded in the MAR. The DON confirmed unawareness of the reasons for these missed doses and acknowledged that medications are expected to be given as ordered.