Failure to Safeguard and Administer Medications as Ordered
Penalty
Summary
The facility failed to maintain a comprehensive pharmaceutical program to safeguard controlled substances and ensure medications were administered as ordered. During a reconciliation of controlled drugs, surveyors observed that controlled medications were not properly labeled or stored. Specifically, two pill-crusher pouches containing an unknown quantity of blue, round, scored tablets were found in a disposable cup labeled only with a resident's name and drug name, but without a pharmacy label or other required identification. The Director of Nursing (DON) was unable to confirm the contents or how long the pouches had been present, and the count of oxycodone tablets did not match the controlled drug record, with missing documentation and discrepancies in the number of tablets available versus what was recorded. Further observations revealed that staff failed to accurately document the administration of controlled medications. In two instances, a registered nurse admitted to administering opioid medications to residents but forgot to sign out the doses on the controlled drug record. Additionally, the number of controlled medication count sheets did not match the number of medication cards, and this discrepancy was not identified during shift change reconciliations. Review of medication administration records and controlled drug records for several residents showed inconsistencies, with some doses recorded as administered on one record but not the other, and in one case, a nurse withheld scheduled pain medication based on personal judgment rather than physician orders. The facility also failed to ensure that antibiotics were administered as ordered. One resident, who had been prescribed a course of Augmentin for pneumonia, did not receive the full number of ordered doses, as confirmed by both the medication administration record and staff interview. Review of facility policies indicated that medications were to be administered as prescribed and that controlled substances were to be properly documented and reconciled, but these procedures were not consistently followed, resulting in multiple deficiencies affecting several residents.