Failure to Provide E-Kit Access Results in Missed Medication Administration
Penalty
Summary
Facility staff failed to maintain professional standards of practice by not ensuring that qualified staff had access to the facility's emergency medication kit (E-Kit), resulting in the failure to administer prescribed medications to three newly admitted residents. The facility's Medication Pass Policy did not include guidance on administering medications from the E-Kit, and staff did not document missed medication administration in the residents' progress notes as required. For each of the three residents, review of their Medication Administration Records (MARs) showed that evening and bedtime doses of multiple prescribed medications were not given on their admission or re-admission dates, with staff noting only to 'see progress notes,' which lacked any documentation of the missed doses. The residents affected included one with high cholesterol and depression, another with hypertension and depression, and a third with cognitive impairment, cerebral vascular accident, and hemiplegia. Each had physician orders for multiple medications, including antihypertensives, muscle relaxants, antidepressants, anticoagulants, and cholesterol-lowering agents. The medications were not administered as ordered due to staff not having access to the E-Kit, and there was no documentation in the progress notes to explain or address the missed doses. Interviews with facility staff revealed that the process for granting E-Kit access was unclear and not consistently implemented. The DON, who was new to the facility, was unaware of who was responsible for setting up E-Kit access. A Certified Medication Technician (CMT) reported not having access since starting employment, and the administrator was unaware that some CMTs lacked access. The President of Clinical Operations confirmed that the DON and pharmacist could set up E-Kit access but was not aware that staff had been unable to administer medications due to lack of access.