Failure to Accurately Account for and Timely Administer Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring accurate accounting and administration of medications for two residents. In one instance, a discrepancy was found during an inspection of a medication cart, where the controlled drug record for oxycodone 10 mg indicated two doses remaining, but only one dose was present in the medication card for a resident. The registered nurse on duty admitted to administering the missing dose earlier in the day but failed to document it immediately on the controlled drug record, citing divided attention due to supervisory responsibilities. In another case, a resident with multiple diagnoses, including aphasia, dysphagia, hypertension, anxiety, depression, and a history of seizures, did not receive several scheduled medications on time. The medication administration audit revealed that five different medications, including atenolol, docusate sodium, Zoloft, Keppra, and clonazepam, were administered nearly four hours late. The licensed vocational nurse responsible for administering these medications confirmed the delay and acknowledged that such late administration could impact the resident's health, especially for medications related to blood pressure, seizures, and mental health. Interviews with both the nurse and the director of nursing confirmed that facility policy requires timely administration and documentation of medications, as well as necessary pre-administration monitoring such as checking vital signs. The director of nursing reviewed the medication administration record and confirmed the delay, noting that staff are required to document medication administration immediately after giving the medication, in accordance with facility policy.