Failure to Ensure Timely Medication Administration and Provider Notification
Penalty
Summary
The facility failed to maintain compliance with previously cited deficiencies related to significant medication errors and failures in provider notification. During a complaint survey, it was found that three residents were not administered scheduled medications, and the provider was not notified of these missed administrations. Additionally, three residents received scheduled medications late, and again, the provider was not notified. Despite ongoing audits and QAPI meetings that reviewed survey results and claimed compliance improvement, documentation revealed continued late and omitted medication administrations during and after the Plan of Correction period. The Director of Nursing was unaware that late medication administrations were still occurring, as this information was not captured in the audits being conducted. The audits performed were random and did not identify ongoing issues with late and omitted medication administrations. The Administrator was unable to explain why the previous Plan of Correction was ineffective and acknowledged that the audits did not detect the continued deficiencies. The facility's QAPI policy assigned responsibility for monitoring the program to the Administrator and Director of Nursing, but the ongoing issues were not identified or addressed through their processes.