Failure to Provide Timely and Accurate Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of all drugs and biologicals to meet the needs of each resident. During a medication pass, twelve residents did not receive their scheduled medications as ordered. Specifically, two residents did not receive any of their 8:00 am medications, and multiple residents received their morning medications more than one hour after the scheduled administration time. The delay was attributed to the unavailability of the electronic Medication Administration Record (MAR) due to an internet outage, and the lack of a paper backup MAR until later in the morning. As a result, all morning medications were administered after 11:00 am on the affected day. Additionally, a Certified Medication Aide (CMA) operated outside her scope of practice by administering an initial dose of a narcotic medication and performing a pain assessment for a resident. According to state regulations and facility policy, CMAs are not permitted to administer the initial dose of a medication that has not been previously given to a resident, nor are they allowed to conduct physical, psychological, or social assessments that require professional nursing judgment. The CMA confirmed in interviews that she administered the first dose of morphine and assessed the resident's pain, actions which were not permitted under her certification. Interviews with facility staff, including the DON and facility physicians, revealed that the physicians were not notified of the late or missed medication administration. The DON was unaware that two residents did not receive their medications at all, and both physicians expressed concern upon learning of the delays and omissions. The facility's own policies and state regulations were not followed, resulting in medication errors including omissions and wrong-time administration for multiple residents with significant medical conditions such as heart failure, hypertension, diabetes, and cognitive impairments.