Medication Administration Errors and Documentation Failures
Penalty
Summary
The facility failed to ensure that prescribed medications were administered as ordered for three residents, resulting in a medication error rate of nine percent. For one resident prescribed digoxin, staff administered the medication after stating they had taken the resident's pulse earlier in the morning, but there was no documentation of any vital signs, including pulse, on the day of administration. The physician's order for digoxin specified to hold the medication if the pulse was less than 50, but this parameter was not verified or documented at the time of administration. Additionally, another resident did not receive their prescribed Lotrimin cream as documented on the Medication Administration Record (MAR), despite the staff member stating they would return to administer non-pill medications after distributing oral medications. The resident, who was cognitively intact, reported not receiving the cream and indicated this was a recurring issue. A third resident, also cognitively intact, reported not receiving their inhaler, although the MAR indicated it had been given. These failures were observed and confirmed through interviews, record reviews, and direct resident statements.