Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to ensure safe medication administration for two residents, resulting in missed doses and improper documentation. For one resident with severe cognitive impairment and multiple health conditions, including metabolic encephalopathy and kidney failure, an order for oyster shell calcium 500 mg twice daily was present in the electronic health record but was not transcribed onto the Medication Administration Record (MAR). As a result, 40 consecutive doses were not administered over a 20-day period. The nurse responsible for medication administration confirmed that the omission was due to the order not appearing on the MAR and acknowledged that the weekly review of active orders had not yet been completed for that week. For another resident with schizophrenia, depression, and low back pain, there were discrepancies in the administration and documentation of controlled medications, including tramadol HCl, lorazepam, and hydrocodone-acetaminophen. The MAR indicated that these medications were administered, but the Narcotic Count Sheet (NCS) and bubble packs showed missing signatures and discrepancies in pill counts. The nurse involved stated that she was too busy to sign the NCS after administering the medications, resulting in missing documentation for multiple doses across different medications. Interviews with nursing staff and the Director of Nursing confirmed that facility policy requires immediate documentation of medication administration on the NCS and that the nurse receiving new orders is responsible for ensuring they are added to the MAR. The lack of proper transcription and documentation was acknowledged as a medication error by both the nursing staff and the Director of Nursing. Facility policies reviewed also supported the requirement for accurate and timely documentation of medication administration.