Medication Administration and Controlled Substance Disposal Deficiencies
Penalty
Summary
The facility failed to ensure appropriate pharmacy services for medication administration and disposal for four residents, as evidenced by direct observations, interviews, and record reviews. For one resident, a registered nurse prepared and was about to administer the incorrect form and dose of prescribed medications, specifically giving tablets instead of capsules for Docusate Sodium and only one tablet instead of two for Magnesium Oxide. The nurse admitted to not having the correct form in supply and did not notify the facility or provider, as required. Another resident was prepared to receive an enteric coated aspirin tablet instead of the prescribed chewable form, with the nurse acknowledging the error and the expectation to follow physician orders and medication rights. A third resident was observed to have insulin prepared and administered without priming the insulin pen, contrary to manufacturer recommendations and facility policy. The staff member confirmed not priming the pen and acknowledged the importance of this step to ensure proper dosing and to avoid air injection. The pharmacist and director of nursing both confirmed that priming is necessary and that staff are expected to follow all medication administration policies and manufacturer instructions. Additionally, the facility failed to follow its own policy for the disposal of controlled substances. For one resident, the destruction of discontinued oxycodone tablets was documented with only one witness signature in the controlled substance accountability record, instead of the required two. Staff interviews confirmed that the process requires two licensed nurses to witness and sign for the destruction, but this was not done in this instance, and the director of nursing acknowledged the omission.