Failure to Ensure Accurate and Timely Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure accurate and timely administration of medications for one resident, resulting in multiple missed doses, late administrations, and incomplete documentation. The resident, who had diagnoses including type 2 diabetes, neoplasm-related pain, acute kidney failure, secondary breast cancer, bone cancer, depression, and anxiety disorder, did not receive her scheduled morning medications on several days, including when she left the facility for a pre-scheduled appointment. There was no documentation in the Medication Administration Record (MAR) for numerous medications on specific dates, and no progress notes explaining the omissions or the resident's absence from the facility. Further review of the MAR revealed that on one occasion, the resident received both her morning and afternoon medications at the same time, and several medications were administered outside the recommended time window, with some doses given four to seven hours late. The facility's medication administration policy requires medications to be given within one hour before or after the scheduled time, with immediate documentation and notation of any delays or omissions, but these procedures were not followed. Interviews with the DON and a Medication Technician confirmed that staff should check appointment logs and communication boards to ensure residents receive medications before leaving for appointments, but this process was not consistently implemented. The Director of Nursing acknowledged the missed medications and lack of documentation, agreeing that progress notes should have been made to explain the omissions. The DON also confirmed that medication administration times should reflect the actual time of administration, and that the facility's practices did not align with policy requirements. No additional documentation was provided to account for the missed or late medications, and the facility did not document any medication errors during the period in question.