Failure to Administer Scheduled Medications Due to Lack of Nursing Staff Coverage
Penalty
Summary
The facility failed to ensure the administration of scheduled morning and afternoon medications for four residents who were reviewed for medication administration. On a specific date, the medication administration records (MARs) for these residents showed blank entries for scheduled doses, indicating that multiple medications were not given as ordered. The residents affected had complex medical histories, including conditions such as spina bifida with hydrocephalus, epilepsy, neurogenic bladder, schizophrenia, and other chronic illnesses, and were dependent on regular medication administration for their health and well-being. Interviews with the residents confirmed that they did not receive their scheduled morning and afternoon medications on the day in question. The residents reported not seeing a nurse on their hall during the day shift, and one resident stated that only a nurse from another floor assisted with personal care but did not administer medications. Another resident reported being told by a CNA that there was no nurse available on the hall that day. The MARs and physician order sheets confirmed that a range of medications, including antiepileptics, anticoagulants, antipsychotics, and other essential drugs, were not administered as scheduled. Staff interviews corroborated that there was no nurse present on the affected hall during the day shift, resulting in the missed medication passes. The facility's policies required medications to be administered according to a standard schedule and for incident reports to be completed immediately after a medication error was discovered. However, the lack of nursing staff coverage led to the omission of medication administration for multiple residents, and the required documentation and follow-up were not completed in a timely manner.