Failure to Administer Medications as Ordered for Two Residents
Penalty
Summary
The facility failed to ensure that two residents received their prescribed medications as ordered by their physicians. One resident, who had recently been hospitalized for serious conditions including sepsis, hematuria, and bacteremia, was admitted to the facility with orders for multiple intravenous and oral antibiotics, as well as diabetic medications and insulin. Despite these orders, the resident did not receive several critical medications, including IV antibiotics, oral antibiotics, insulin injections, and oral diabetic medications, during their stay. The medication administration record (MAR) showed missing documentation for these medications, and there was no explanation for the omissions in the progress notes. The resident's blood sugar was only checked once, and the facility's automated medication system had the required antibiotics available, yet they were not administered or documented as given. Interviews with facility staff, including the DON and ADON, confirmed that the medications in question were available in the facility's emergency medication system. The DON was unable to explain why the medications were not administered or documented, and stated that staff were required to document reasons for any missed doses. The nurse practitioner confirmed that she was not notified about the unavailability or potential allergy concerns regarding the antibiotics, which was not standard practice. The resident was eventually transferred back to the hospital due to a change in condition, including fever and lethargy, and did not return to the facility. A second resident with a history of heart failure, hypertension, and atrial fibrillation did not receive all prescribed anti-hypertensive medications during a medication pass. The LPN administered one blood pressure medication but withheld two others without provider-specified parameters for holding the medications. The LPN was unable to explain the rationale for withholding the medications and did not consult the provider as expected. The nurse practitioner confirmed that, in the absence of specific hold parameters, the medications should have been administered, and the DON reiterated that staff were expected to follow provider orders or seek guidance if uncertain.