Failure to Accurately Document and Administer Medications
Penalty
Summary
The facility failed to ensure accurate documentation and administration of medications for two residents. For one resident admitted as a hospice respite patient, there were orders for as-needed pain and anxiety medications, including Tylenol, Morphine, and Lorazepam. Although the controlled drug administration records and hospice notes indicated that these medications were administered, there was no corresponding documentation in the resident's Medication Administration Record (MAR). The Assistant Director of Nursing confirmed that all controlled medications taken should be signed out in both the controlled log book and the MAR, but this was not done. For another resident with a history of hypertension, cardiomyopathy, congestive heart failure, pulmonary hypertension, and atrial fibrillation, the MAR showed that several medications were not administered as ordered and were coded with reasons such as vital signs out of parameters or other notes, despite no such parameters being specified in the medication orders. Some medications were also not given due to awaiting delivery or order issues. The Regional Director of Nursing stated that medications were held based on nursing judgment, but could not confirm if the provider was notified when medications were withheld. The attending physician stated that he would expect to be notified if medications were not administered as ordered, especially when coordinated with specialists.