Failure to Administer Medications as Ordered and Inadequate Documentation
Penalty
Summary
The facility failed to administer medications as ordered for two of three sampled residents reviewed for medication administration. For one resident with type 2 diabetes mellitus, the medication administration record indicated that insulin glargine was not administered as ordered on a specific date, with staff unable to explain the meaning of the documentation mark used. There was no documentation that the insulin was given, and staff interviews confirmed uncertainty about the record and the process for documenting refusals or missed doses. For another resident with diagnoses including congestive heart failure and atrial fibrillation, there was no documentation that magnesium oxide was administered over a three-week period. Additionally, the medication administration records for ciprofloxacin and metoprolol showed missed or held doses, with staff unable to consistently explain the reasons for these actions or the documentation used. The resident reported sometimes not receiving medications even when requested. Staff interviews revealed confusion about medication parameters, documentation codes, and the process for holding or administering medications, with the DON confirming that some medications were not administered as ordered.