Medication Administration and Management Deficiencies
Penalty
Summary
The facility failed to implement pharmaceutical policies and procedures consistent with standards of practice, resulting in multiple medication administration errors and lapses in medication management. In one instance, a nurse administered only one capsule of Flomax to a resident when the physician's order specified two capsules to be given 30 minutes after the same meal each day. The medication was also administered before breakfast, contrary to the prescribed timing. The nurse acknowledged the error and confirmed that the medication was not given as ordered. Another resident did not receive a prescribed dose of Valsartan for hypertension because the medication was not available at the time of administration. The nurse reported that a refill request had been faxed to the pharmacy, but there was a delay in delivery. The medication administration record confirmed that the scheduled dose was missed, and the DON acknowledged that pharmacy delivery issues sometimes led to such delays. A third resident did not receive prescribed topical antifungal treatment for several days due to unavailability of the medication. Nursing progress notes repeatedly documented that the medication was either awaiting delivery from the pharmacy or not available in house supply, and there was no evidence that the physician was notified about the missed doses. Additionally, expired medication was administered to another resident, and a loose, unidentified pill was found stored with controlled substances, as well as a loose pill observed on the hallway floor. These incidents were confirmed by staff interviews and direct observation, and were not in accordance with facility policies for safe medication administration and management.