Failure to Ensure Proper Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure that residents' medications were ordered in advance and administered as prescribed. Multiple instances were observed where residents were given medications that were prescribed for other residents when their own supply ran out. This practice was confirmed through medication card reviews, interviews with nursing staff, and documentation, showing that doses were removed from one resident's medication card and administered to another resident. The facility's own policies explicitly prohibit administering medications supplied for one resident to another, yet this practice was ongoing and had become routine among nursing staff. Several residents were affected by this deficiency, including those with complex medical histories such as hemiplegia, hypothyroidism, diabetes, schizoaffective disorder, chronic kidney disease, and post-surgical aftercare. Medication administration records and pharmacy receipts revealed that medications such as levothyroxine, potassium chloride, glipizide, clozapine, oxycodone, and pregabalin were borrowed from one resident and given to another. In some cases, the medication cards were annotated to indicate which resident received the borrowed dose, but there was often no clear documentation or rationale for the removal of doses, and the process for replacing borrowed medications was unclear to staff. Interviews with nursing staff, including RNs and LPNs, confirmed that they had received direction from nursing leadership, including the DON, to borrow medications from other residents when a medication was not available for the intended resident. This direction was given multiple times and had become a long-standing practice in the facility. Staff reported that they would attempt to reorder medications when supplies were low, but if the medication was not available, they would check the emergency medication kit or call the pharmacy. If the medication was still unavailable, they were instructed to borrow from another resident's supply. This practice was not communicated to residents or their families, and some staff expressed awareness that this was not a proper nursing practice.