Failure to Follow Professional Standards in Medication Administration and Management
Penalty
Summary
The facility failed to meet professional standards of practice in several areas related to medication administration and management. One resident with hypothyroidism had a physician's order for levothyroxine to be administered at 6:00 AM, prior to breakfast and on an empty stomach. However, medication administration records showed that the medication was frequently given more than one hour after the scheduled time, often after breakfast, on 27 out of 36 reviewed days. Both the resident and nursing staff confirmed that the medication was not being administered as ordered, and staff acknowledged that this did not meet expectations for proper medication timing. Another resident with hypertension had an order for lisinopril 20 mg twice daily, with instructions to hold the dose if systolic blood pressure was below 100. The resident reported that at home, they only took the medication once daily and expressed concern about receiving too much medication at the facility. Documentation showed that the medication was held on several occasions due to low blood pressure, and a progress note indicated the resident's concern about the dosing. However, there was no evidence that staff communicated this concern to the provider or followed up to clarify the appropriate dosing regimen. Additional deficiencies were observed in medication administration practices, including a resident receiving a chewable aspirin tablet in a manner inconsistent with the order, as the resident preferred to swallow all medications together rather than chew the tablet. Staff did not seek a provider order to change the medication form. Furthermore, a controlled substance (Oxycodone) was found improperly stored in a plastic bag attached to the controlled substance book, rather than being wasted immediately as required. Staff acknowledged that the leftover medication should have been destroyed promptly, but this was not done.