Failure to Administer and Document Medications as Ordered
Penalty
Summary
Staff failed to administer and document medications as ordered by physicians for three residents, resulting in a failure to meet professional standards of quality. Facility policies required that all physician orders be accurately transcribed and followed, and that medication administration be documented on the Medication Administration Record (MAR) immediately after administration. However, review of the MARs for the three residents revealed multiple instances where medications were either not documented as given or left blank, with no corresponding progress notes to explain the omissions. One resident with diagnoses including orthopedic conditions and depression had several medications, such as Duloxetine, Famotidine, and Hydroxychloroquine, that were not documented as administered on multiple dates. The resident reported issues with receiving pain medications, and there was no documentation in the progress notes regarding the missed doses. Another resident with high blood pressure, end stage renal disease, anxiety, and depression also had several medications, including Nortriptyline, Melatonin, and Amlodipine, left undocumented on the MAR for multiple days. This resident reported not receiving their Nortriptyline and was unsure about other missed medications. A third resident with heart failure and acute kidney failure had orders for Hydralazine and Isosorbide Dinitrate, with several doses not documented as administered and no progress notes explaining the omissions. Interviews with staff confirmed that the MAR should be initialed after medication administration and that any missed doses should be documented with reasons. The Director of Nursing and Administrator both stated that the facility's policies required strict adherence to these procedures, and that failure to document indicated the medication was not given as ordered.