Failure to Administer and Reorder Medications Timely, Resulting in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that medications were administered timely and as ordered, and did not consistently reorder medications to prevent running out, resulting in significant medication errors for four residents. For one resident, a change in Tramadol order from PRN to scheduled dosing was not properly managed, leading to missed doses due to delays in obtaining a signed prescription and confusion over whether the medication should be administered as needed or on a schedule. Documentation showed that the resident was without Tramadol for multiple scheduled doses, and staff and pharmacy communications revealed delays in reordering and confusion about medication supply responsibilities. Another resident experienced a lapse in receiving Norco due to the facility running out of the medication and delays in sending a signed prescription to the pharmacy. This resident also had multiple instances where other medications, including insulin and antihypertensives, were administered significantly later than scheduled, with no documentation of physician notification regarding these delays. Nursing notes confirmed the lack of timely communication with the physician and delays in medication administration. A third resident did not receive scheduled doses of Amlodipine and Metoprolol on several occasions, with the nurse withholding the medications based on blood pressure readings despite the absence of physician-ordered parameters for withholding. There was no documentation of physician notification for these withheld doses. Additionally, another resident reported repeated delays in receiving evening medications, with audit reports confirming multiple instances of late administration. Staff interviews attributed these delays to workload and staffing issues, and the DON confirmed the expectation for timely administration and documentation, which was not met in these cases.