Failure to Document and Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring accurate administration and documentation of physician-ordered medications for six residents. Staff did not consistently document medication administration in the Medication Administration Record (MAR) as required by facility policy, resulting in multiple undocumented doses across a range of medications, including insulin, antipsychotics, pain medications, antibiotics, and medications for chronic conditions such as hypertension, COPD, and diabetes. The facility's policy required staff to document all administered medications, note refusals, and provide reasons for any missed doses, but these procedures were not followed. Residents affected had complex medical histories, including diagnoses such as chronic obstructive pulmonary disease, schizophrenia, diabetes, hypertension, depression, and recent acute medical events like peptic ulcer with hemorrhage and perforation. For example, one resident with diabetes and chronic pain did not have documentation for several doses of insulin, pain medication, and other prescribed drugs. Another resident with hypertension, COPD, and a history of fractures had multiple undocumented doses of blood pressure medication, pain medication, and antibiotics. In several cases, there was no documentation in the nurses' progress notes to explain the missed or undocumented doses. Interviews with residents revealed that some experienced increased pain, missed doses, and inconsistent medication administration, which affected their comfort and ability to sleep. Staff interviews confirmed that documentation was sometimes omitted due to being busy, and blank areas on the MAR were not in accordance with policy. The Director of Nursing and Administrator were unaware of the extent of the documentation lapses and missing doses, despite policies requiring staff to notify them if medications were unavailable or not administered.