Medication Administration and Documentation Errors
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for two of four sampled residents. In one case, a resident admitted after hip surgery with multiple diagnoses, including high cholesterol, coronary artery disease, parkinsonism, and cognitive impairment, had a physician order for Aspirin 81mg twice daily to prevent clotting. However, the medication order was incorrectly transcribed into the electronic Medication Administration Record (eMAR) as 81mg once daily, resulting in the resident not receiving the prescribed dose for several weeks after admission. The error was only corrected weeks later, and the resident did not receive the correct dosing until that time. In another instance, a resident with paralysis, nerve pain, osteoarthritis, hypertension, and high cholesterol, who was dependent for mobility and activities of daily living, did not receive prescribed evening medications (Carbamazepine and Famotidine) on two separate occasions. The eMAR showed no documentation of medication administration, refusal, or the resident being out of the facility, and the required codes or progress notes were absent. Staff interviews confirmed that the medications were not administered and that the expected documentation was not completed.