Failure to Ensure Timely Medication Administration and Accurate Controlled Drug Documentation
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of a prescribed intravenous antibiotic for one resident who was readmitted from the hospital with sepsis and a urinary tract infection, and who required IV medication via a PICC line. Despite a physician's order for Meropenem to be administered every 12 hours for five days, the medication was not available for administration on two separate occasions, resulting in missed doses. Facility policy required staff to check the automated medication dispensing system, contact the pharmacy for STAT delivery, notify the physician and resident representative if the medication was unavailable, and document these actions. However, the clinical record lacked documentation that the physician or resident representative was notified of the missed doses, and the resident did not receive the full course of prescribed antibiotic therapy. The Nursing Home Administrator confirmed that backup pharmacy resources were available but not utilized to prevent the missed doses. Additionally, the facility failed to maintain accurate controlled drug shift count documentation on one of two medication carts reviewed. Facility policy required Schedule II medications to be counted and verified at each shift change by both oncoming and outgoing nurses, with signatures required to verify accuracy. Review of the controlled medication shift change log revealed missing signatures on multiple occasions, and staff interviews confirmed that the required sign-offs were not completed. The Nursing Home Administrator acknowledged the facility's failure to consistently adhere to procedures for verifying and documenting controlled substance counts.