Failure to Administer and Document Resident Medications as Prepared
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including dementia and cognitive communication deficit, did not receive her prescribed evening medications as intended. The medications, which included alprazolam, aspirin, atorvastatin, carvedilol, clopidogrel, and Seroquel, were found in a cup in the resident's room by her family member, rather than being administered. The nurse on duty disposed of the medications after confirming they were missed doses from the previous evening, but did not document the incident or report it at the time. The Medication Administration Record (MAR) incorrectly indicated that the medications had been given, with no notation of a missed dose or medication error. Further review revealed that the facility lacked a specific policy for medication errors, though their medication administration policy required documentation in the event a medication could not be given. The Director of Nursing confirmed that a medication error report should have been completed in this situation, but it was not done until after the incident was discovered. The failure to administer the medications as prepared, document the missed dose, and report the error constituted a deficiency in pharmaceutical services for the resident.