Failure to Administer Medications as Ordered and Document Appropriately
Penalty
Summary
The facility failed to ensure that residents received their medications as ordered, resulting in significant medication errors for two residents. One resident with diagnoses including obstructive uropathy and coronary artery disease did not receive prescribed Ciprofloxacin for a urinary tract infection and Aspirin for amaurosis fugax as ordered. The Medication Administration Record (MAR) was left blank for both medications, and there was no documentation explaining the omissions. Staff interviews revealed that the antibiotic was not available in the facility's medication cart and was not delivered in time, despite the pharmacy having the capability to provide the medication promptly. The omission of Aspirin was attributed to the form of the medication, but there was no documentation of provider clarification in the resident's record. Another resident with high blood pressure and chronic pain did not receive Hydralazine as needed when their systolic blood pressure exceeded the ordered threshold, and there was no documentation on the MAR to explain the omission. Additionally, Voltaren gel for pain management was marked as unavailable on multiple days. Staff interviews confirmed that nurses were responsible for ordering medications and acknowledged that the medications should have been administered as ordered. The lack of medication administration and documentation directly led to the identified deficiencies.