Failure to Monitor and Administer High-Risk Medications Appropriately
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary drugs due to inadequate monitoring, administration, and care planning for high-risk medications. For one resident with chronic lymphocytic leukemia and dementia, the care plan did not address cancer, the use of cytotoxic medication, or include interventions for monitoring adverse side effects or guidance for specialized handling. During medication administration, staff were observed not using gloves when handling Imbruvica, a cytotoxic medication, and staff interviews revealed a lack of awareness regarding necessary precautions and monitoring for side effects such as hemorrhage. For another resident with a history of liver transplantation, liver cancer, and chronic hepatitis, the physician's orders for Tacrolimus did not specify the need for administration at the same time each day, which is required to maintain therapeutic blood levels. The resident's medication administration records showed multiple instances where Tacrolimus was given late, early, or missed entirely. Additionally, laboratory tests to monitor therapeutic levels of Tacrolimus had not been obtained since admission, and the care plan did not address the transplant, immunosuppressive therapy, or monitoring for side effects and special administration instructions. Staff interviews indicated a lack of knowledge regarding the handling and monitoring of both cytotoxic and immunosuppressant medications. The contracted pharmacist confirmed the need for routine monitoring and administration protocols but had not ordered necessary lab tests, and the DON acknowledged the absence of additional monitoring or education for residents on immunosuppressant therapy. These deficiencies were observed and confirmed through record review, staff interviews, and direct observation.