Failure to Timely Administer Admission Medications and Complete Admission Procedures
Penalty
Summary
The facility failed to timely and accurately complete the admission process and administer medications as ordered for a newly admitted resident. Upon review, it was found that the resident, who was admitted with diagnoses including pneumonia, sepsis, and a need for assistance with personal care, did not receive her scheduled evening medications on the day of admission. The resident's hospital discharge medication list included several medications due that evening, but the Medication Administration Record (MAR) showed that these medications were not scheduled to begin until the following day. Although one of the required medications, Eliquis, was available in the facility's backup supply, it was not administered. The resident arrived at the facility in the evening, after the cutoff for the nightly medication delivery, and the medications were not entered into the system until after midnight, spanning two nursing shifts. The process required one nurse to input all medications and a second nurse to review for accuracy and notify the physician, but this was not completed in a timely manner. Additionally, the facility administrator was unaware of a concern form submitted by the resident regarding the missed medications, and no documentation of this concern was found in the facility's records. The administrator explained that some records may have been lost when the previous DON left the facility.