Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered and documented as ordered by the physician for two residents. For one resident with diagnoses including hypertension, type II diabetes mellitus, hyperlipidemia, and neuropathy, there were multiple instances over two months where medications and required monitoring (such as blood pressure checks and blood glucose monitoring) were either not performed or not documented. Many medication doses were left blank on the Medication Administration Record (MAR), with no documentation in the nurse's notes explaining the omissions or indicating that the physician was notified. In several cases, medications were held without physician orders or parameters, and there was no record of communication with the physician regarding these actions. Another resident with multiple chronic conditions, including hypertension, diabetes, hyperlipidemia, COPD, depression, anxiety, and insomnia, also experienced missed medication doses. Several medications were not administered as ordered, with doses left blank on the MAR and no documentation as to why the medications were missed or whether the physician was notified. Some missed doses were due to resident refusal, but others had no explanation or documentation of follow-up. In at least one instance, a medication was not available from the pharmacy, and there was no documentation of physician notification or use of the emergency kit as outlined in facility policy. Interviews with staff, including CMTs, LPNs, the DON, and the nurse practitioner, revealed inconsistent practices regarding documentation, physician notification, and medication administration when residents were out of the facility or refused medications. Staff acknowledged that missed doses were not always documented, and the nurse practitioner was not consistently notified of refusals or patterns of missed medications. The facility's own policies require documentation of missed doses, reasons for omissions, and physician notification, but these procedures were not followed, resulting in the identified deficiencies.