Deficient Documentation and Administration of Controlled Medications and IV Antibiotics
Penalty
Summary
The facility failed to document and administer controlled medications and intravenous (IV) antibiotics in accordance with physician orders and regulatory requirements for several residents. For one resident with end stage renal disease and opioid dependence, controlled drug administration records for oxycodone were incomplete and illegible, with missing dates, times, and staff signatures. The records showed inconsistencies with the prescribed dosing interval and as-needed administration, and the medication counts did not reconcile with the documented administrations. Similar documentation issues were found for another resident receiving oxycodone, where the count correction lacked a date, time, and signature, and the administration record contained illegible and crossed-out entries. For another resident with hypertension and lymphedema, the facility failed to ensure timely and complete administration of IV ceftriaxone, resulting in two missed doses out of fourteen ordered. Additionally, a newly admitted resident with multiple bowel perforations and intra-abdominal abscesses did not receive timely IV antibiotics and antifungal medications upon admission. Orders for these medications were not entered until the day after admission, leading to missed doses. The resident and her family reported delays in medication administration, and the medication administration record did not reflect the administration of all ordered medications. The facility's controlled drug administration records also lacked proper reconciliation for medications delivered and administered, including missing documentation for narcotic counts and administration of pain medications and sedatives. The facility's policy required shift-to-shift narcotic counts and immediate investigation of discrepancies, but the records reviewed did not consistently meet these requirements. These deficiencies were identified through interviews, record reviews, and review of facility policies.