Failure to Administer Medications as Prescribed and Improper Borrowing of Resident Medications
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed for three residents out of eight reviewed for medication administration. Specifically, one resident with multiple diagnoses, including a humerus fracture, diabetes, malnutrition, hypertension, and intracerebral hemorrhage, had a physician order for Carvedilol 25 mg twice daily. Another resident with congestive heart failure, interstitial lung disease, diabetes, psychotic disorder, and dementia had an order for Fenofibrate 145 mg at bedtime. A third resident with diastolic heart failure, bipolar disorder, anxiety, noncompliance with medical treatment, and cellulitis had multiple medication orders, including Depakote ER, Fenofibrate, Valsartan, Colace, Digoxin, Carvedilol, Spironolactone, Eliquis, and Flomax. On a specific date, the Medication Administration Record showed that the third resident was scheduled to receive several medications at 9:00 PM but only received a partial dose of Colace and refused the rest. During an interview, an LPN admitted to borrowing medications from other residents, including Fenofibrate and Carvedilol, to administer to the third resident because the resident's own medications were unavailable. The LPN stated it was easier to obtain medications from other residents than from the emergency drug supply. Facility policy explicitly prohibited administering medications ordered for one resident to another. This practice was confirmed as a deficiency under the cited complaint numbers.