Failure to Administer Ordered Medications and Complete Assessments
Penalty
Summary
The facility failed to follow physician orders and professional standards of quality for one resident by not administering prescribed medications and not completing required assessments as ordered. The resident, who had diagnoses including hypertension, hyperlipidemia, anxiety disorder, acid reflux, and uncontrolled diabetes, was admitted in the evening and had several medications ordered, including gabapentin, Pepcid, rosuvastatin, and extra strength Tylenol. Despite these medications being available through the facility's Pyxis system and as stock medications, staff did not administer them as ordered and did not document appropriate reasons for the omissions. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed that on multiple occasions, the administration boxes for the resident's medications were either marked as not administered or left blank, and pain assessments were not consistently documented. Progress notes indicated that medications were not available, but there was no documentation that staff attempted to obtain the medications from the Pyxis system, even though they were available. Additionally, extra strength Tylenol, which was available as a stock medication, was not administered. Interviews with nursing staff revealed that an agency LPN did not have access to the Pyxis system and therefore did not administer the medications. The DON confirmed that medications should be administered as ordered, and that staff are expected to utilize the Pyxis or stock medications if the resident's medications are unavailable. The facility had processes in place for obtaining medications after hours, but these were not utilized, and there was no documentation to support that all available resources were used to provide the ordered medications and assessments.