Failure to Administer and Document Medications According to Policy
Penalty
Summary
Surveyors identified that the facility failed to administer medications in accordance with accepted nursing standards and the facility's own medication administration policy for four out of seven sampled residents. For one resident with multiple chronic conditions, a one-time dose of Fosfomycin Tromethamine for a urinary tract infection was ordered but not documented as administered, and there was no evidence that the primary care physician (PCP) was notified of the missed dose or any refusal. Additionally, there was no documentation in the progress notes regarding the missed administration or any resulting harm. For three other residents, multiple scheduled medications were not administered within the required time frame of one hour before or after the scheduled dose, as stipulated by facility policy. The medications included treatments for constipation, infection, pain, hypertension, cough, and glaucoma. The medication administration records (MAR) and audit reports showed repeated late administrations, sometimes by several hours, with no documentation explaining the delays or indicating that the PCP was notified. Progress notes for these residents also lacked any mention of the late administrations or communication with the PCP, and there was no documented evidence of harm resulting from the delays. Interviews with nursing staff and the Director of Nursing (DON) confirmed that facility policy requires medications to be administered within a one-hour window of the scheduled time and that any late or missed doses should be documented, with the PCP notified as appropriate. However, the DON was unable to confirm whether the missed dose for the resident with the UTI was given, and staff interviews revealed inconsistent documentation practices. The facility's policy on medication administration, dated September 2024, was reviewed and confirmed the one-hour administration window requirement.