Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident. Specifically, the resident did not receive multiple prescribed medications, including Furosemide, Spironolactone, Alprazolam, Metronidazole, and Midodrine HCl, on several scheduled occasions. Medication Administration Records (MAR) showed missed doses, and there was no documentation to indicate whether the medications were administered or the reasons for omission. The resident involved was an adult female with diagnoses including spontaneous bacterial peritonitis, streptococcal infection, and generalized anxiety disorder. Her care plan included the administration of anti-anxiety medications as ordered by her physician, but there was no care plan addressing medication refusal or missed doses. The resident's cognitive status was intact, as indicated by a BIMS score of 15 on her admission MDS. Interviews with nursing staff and medication aides revealed that it was the responsibility of the person administering medications to document administration in the electronic MAR (EMAR). Staff confirmed that if administration was not documented, it could not be confirmed that the medication was given. Facility policy required that all medication administration be recorded in the EMAR, and if a medication was not administered, the reason should be documented and the physician or nurse practitioner notified. However, in this case, there were blanks in the EMAR with no documentation or explanation for the missed doses.