Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for three residents who were sampled for timely medication administration. Review of the facility's policy indicated that medications should be given within a defined window of time, and any missed doses should be documented with an explanation. However, medication administration records for all three residents showed multiple missed doses of various prescribed medications, with no explanations documented in the medical records for these omissions. For one resident with diagnoses including hypertensive chronic kidney disease and type II diabetes mellitus, missed doses included antihypertensives, insulin, and other critical medications over several days. Another resident with a history of convulsions, encephalitis, and edema had missed doses of anticonvulsants, diuretics, and statins, again with no documentation explaining the missed doses. A third resident with chronic kidney disease, atrial fibrillation, and insomnia also had several missed doses of anticoagulants, diuretics, and other medications, with no recorded reasons for the omissions. Interviews with facility staff, including the corporate nurse consultant and the DON, confirmed that there was no way to determine if the missed doses were actually administered, as staff were not documenting appropriately on the medication records. The lack of documentation and unexplained missed doses directly contravened facility policy and physician orders, resulting in a deficiency related to pharmaceutical services and medication administration.