Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide necessary pharmaceutical services to meet the needs of several residents, as evidenced by multiple deficiencies in medication management and administration. For one resident, hydromorphone, a controlled medication, was signed out on the Controlled Medication Count Sheet on several occasions, but there was no documentation in the Medication Administration Record (MAR) to confirm that the medication was actually administered. The Unit Manager confirmed that staff are required to document administration of controlled medications on both the MAR and the Controlled Medication Count Sheet, but this was not done for the specified dates and times. Additionally, the facility did not ensure timely removal of unused or discontinued controlled medications from medication carts for three residents. In these cases, controlled medications such as hydrocodone/APAP and lorazepam were found in the medication carts with no active physician orders, and the medications had not been administered. The Unit Manager verified that these medications remained in the carts despite the orders being discontinued, and the corresponding Controlled Medication Count Sheets reflected that the medications were not used. There were also failures in medication administration practices. During a medication pass, a nurse was observed leaving a resident's medications unattended on the bedside table on two separate occasions while leaving the room to retrieve supplies. The nurse acknowledged that medications should never be left unattended. Furthermore, another resident received a blood pressure medication despite the resident's systolic blood pressure being above the physician-ordered hold parameter. The nurse who administered the medication confirmed that the medication should not have been given under those circumstances.