Failure to Administer Medications as Ordered and Inadequate Documentation
Penalty
Summary
Surveyors identified that medications were not administered in accordance with professional standards of nursing practice for three residents. In one instance, a resident with diagnoses including anxiety disorder, schizoaffective disorder, and chronic pain did not receive their scheduled pain patch or gel as ordered. The electronic medication administration record (eMAR) indicated the medications were given, but the LPN admitted they had not yet administered them and had signed off in error. The nurse also failed to notify the physician promptly about the missed doses, and the medications were available in the backup supply. Another resident with rheumatoid arthritis did not receive a scheduled dose of Voltaren gel and a newly ordered dose of Methylprednisolone. The eMAR showed the medication was held with a note to see progress notes, but there was no corresponding documentation explaining the omission or any follow-up with the physician. The facility was unable to provide an investigation or further documentation regarding the missed medications, and the consultant pharmacist confirmed that nurses are expected to check backup supplies and notify the physician if medications are unavailable. A third resident with dementia and depression had multiple medications not administered as ordered, with nurses documenting "awaiting delivery" despite the medications being available in the backup supply and in the medication cart. There was no evidence that the physician was notified about the missed doses. The facility's policy requires medications to be administered as prescribed and within one hour of the scheduled time, but this was not followed in these cases.