Failure to Ensure Proper Pharmaceutical Services and Medication Accountability
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents and in one medication room, resulting in multiple deficiencies. For one resident with a history of cerebral infarction, dementia, and urinary tract infection, the facility received eight tablets of Augmentin as ordered by the physician. However, only seven tablets were administered and documented, with the remaining tablet unaccounted for. The Medication Disposition Log was not completed for the extra tablet, and the bubble pack was missing. The Director of Nursing acknowledged that the medication was likely discarded without proper logging, contrary to facility policy, which requires all discontinued or leftover medications to be logged and destroyed in the presence of two licensed nurses. Another resident with Parkinson's disease was prescribed carbidopa-levodopa extended-release to be administered at midnight, in addition to immediate-release doses throughout the day. The Medication Administration Record showed that the extended-release dose was consistently given at 6:30 a.m. instead of midnight, as ordered by the physician. Both the registered nurse and the Director of Nursing confirmed that this constituted a medication error, as the medication was not administered according to the prescriber's order, and the timing was not in accordance with facility policy. Additionally, in one medication room, an emergency medication kit containing controlled medications was not reconciled at every shift change as required. The kit, stored in a refrigerator, lacked an accountability log for the month reviewed. Staff interviews confirmed that all controlled medications, including those in emergency kits, should be reconciled at each shift change to ensure accountability and prevent diversion. The Director of Nursing confirmed that this process was not followed for the emergency kit in question.