Failure to Administer Medications as Prescribed and Incomplete Documentation
Penalty
Summary
The facility failed to ensure that multiple residents received their prescribed medications as ordered by their physicians, as evidenced by interviews and record reviews. Six sampled residents did not receive various medications, including critical treatments for conditions such as schizoaffective disorder, diabetes, hyperlipidemia, anxiety, depression, and infections. Missed doses were documented across several medication types, including oral tablets, injectables, and topical treatments, with some residents missing multiple consecutive doses. In some cases, entire courses of antibiotics or essential daily medications for chronic conditions were not administered as prescribed. Residents reported that they did not consistently receive their medications, attributing missed doses to staff shortages or medications being on order. Some residents specifically denied refusing their medications, indicating that the missed doses were not due to resident choice. Documentation on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) was often incomplete, with missing notes regarding the reason for non-administration or lack of notification to the physician or nurse practitioner when medications were not given, even when required by facility policy. Interviews with staff, including Certified Medication Technicians (CMTs), LPNs, the Director of Nursing (DON), and the Administrator in Training (AIT), revealed a lack of awareness regarding the extent of missed medication doses. Staff confirmed that medications are to be administered as ordered and that refusals or missed doses should be documented and reported to the appropriate medical provider. However, both the DON and the nurse practitioner stated they were not aware of the missed medications or lack of documentation, indicating a breakdown in communication and adherence to established medication administration protocols.