Medication Administration and Disposal Deficiencies
Penalty
Summary
The facility failed to administer medications in accordance with physician orders and professional standards of practice for multiple residents. One resident with Type 2 Diabetes Mellitus did not receive metformin within one hour of the scheduled administration time on several occasions, as required by facility policy. The medication was intended to be given at 8:00 a.m. with meals, but was administered late on multiple days, including one instance where it was given at 10:00 a.m. instead of by 9:00 a.m. Staff interviews confirmed that this delay was outside the facility's policy and could affect the resident's blood glucose control. Another resident with a history of atherosclerosis and breast cancer did not receive aspirin 81 mg chewable tablet as intended. During medication administration, the nurse did not instruct the resident to chew the tablet, and the resident swallowed it whole, contrary to manufacturer instructions. Additionally, the same nurse failed to wear gloves while handling letrozole, a hazardous medication, despite facility policy requiring personal protective equipment for hazardous drugs. Staff interviews confirmed that these actions were not in line with facility protocols and manufacturer requirements. The facility also failed to ensure the proper disposal of discarded medications. Observations of three medication carts revealed that loose tablets, capsules, and liquids were stored in open red biohazard containers within the carts, making the medications accessible and not irretrievable as required by policy. Staff interviews indicated that both controlled and non-controlled medications were sometimes disposed of in this manner, and that the method did not guarantee medications could not be retrieved. The DON confirmed that this practice was not compliant with facility policy and posed a risk for accidental exposure or misuse.