Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper pharmaceutical services and medication administration for several residents, as evidenced by multiple deficiencies observed during survey. One resident with a history of hypertension, osteoarthritis, and glaucoma did not receive metoprolol succinate ER within 60 minutes of the scheduled time on multiple occasions, contrary to facility policy. Additionally, this resident had duplicate orders for diclofenac (Voltaren) topical gel that were not clarified or discontinued, and there was inaccurate documentation of medication administration, including instances where medications were documented as given when they were not administered. The same resident was found to have eye drops at bedside despite being assessed as unable to self-administer, and some prescribed eye medications were unavailable or not administered as ordered. Another resident with severe cognitive impairment was prepared to receive vitamin B complex instead of the ordered thiamin (vitamin B-1), and the error was only identified after the medication was refused. The facility staff prepared the incorrect medication, and there was no physician order for vitamin B complex. In a separate incident, a resident with diabetes and neuropathy received Ciprodex otic suspension incorrectly, as the nurse did not shake the suspension before administration and instilled the drops with a five-minute interval between each drop, causing discomfort and deviating from professional standards and facility policy, which required all drops to be instilled at once followed by a five-minute wait. Controlled medication documentation was also found to be inaccurate for two residents. For one resident, the count of pregabalin capsules did not match the controlled drug record (CDR) or the electronic medication administration record (eMAR), as the nurse failed to document administration in the CDR immediately after giving the medication. Similarly, for another resident prescribed lacosamide for seizures, the medication count and documentation were inconsistent, with the nurse admitting to forgetting to document on the controlled count sheet. These documentation lapses were confirmed by the DON, who acknowledged the importance of accurate and timely documentation for controlled substances.