Failure to Administer and Document Prescribed Medications
Penalty
Summary
The facility failed to ensure that medications were prepared and administered as prescribed for two residents. For one resident with diabetes, there were multiple instances where documentation was missing for both Insulin Lispro and Lantus administrations, particularly during evening doses. The missing documentation coincided with elevated blood glucose readings, and the resident reported missing at least three doses in the past month, often needing to remind staff to administer her insulin. She described feeling unwell when doses were missed and noted that the issue primarily occurred during evening medication rounds. The care plan for this resident required staff to administer medications as ordered and monitor for signs of hyperglycemia and hypoglycemia, but these instructions were not consistently followed. Another resident with glaucoma and macular degeneration was prescribed daily Latanoprost eye drops, but the medication was marked as unavailable and not administered on several occasions over a span of days. The resident reported discomfort and was told by staff that the medication was unavailable for at least a week. Staff interviews revealed that nurses were aware of the procedures for medication administration and documentation, and the DON confirmed that the only documentation for medication administration was in the MAR. However, there was no available policy on the accuracy of medication administration, and staff were unfamiliar with the specific instances of missed doses for these residents.