Medication Documentation and Availability Discrepancies
Penalty
Summary
The facility failed to ensure that there were no discrepancies between a resident's available medications, the resident's medication orders, and the medication administration record (MAR). During a review of a resident's medications, a bottle of lorazepam was found in the medication storage room with a label indicating it was prescribed for the resident, with specific administration instructions. However, the facility's electronic health record did not include an order for lorazepam, and the medication was not listed on the resident's MAR. The RN confirmed that the medication had been delivered by the hospice agency's pharmacy, but it was not properly documented in the facility's records. Additionally, the resident had an order for C-PDR cream to be applied as needed for nausea or vomiting, which was part of the hospice comfort package. The RN stated that the facility did not have the C-PDR cream available for the resident. The Director of Nursing confirmed that all medications ordered for a resident should be available in the facility. Facility policy required that a current list of orders be maintained in the clinical record for each resident, and the pharmacy services contract required regular medication regimen reviews by a consultant pharmacist.