Failure to Administer and Document Medications per Policy
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to administer and document medications according to facility policy and physician orders for a resident with multiple complex medical conditions, including sepsis, acute respiratory failure, schizoaffective disorder, seizure disorder, dementia, and hypertensive chronic kidney disease. The resident had specific medication orders for divalproex sodium, apixaban, olanzapine, and metoprolol succinate, with scheduled administration times. The LVN administered divalproex sodium, apixaban, and olanzapine at 7:30 a.m., which was earlier than the scheduled 9 a.m. time, and outside the facility's policy of administering medications within one hour of the scheduled time unless otherwise specified. The LVN did not document the early administration of these medications at the time they were given. Instead, documentation was completed later in the medication administration record (MAR), and the administration was recorded as occurring at the scheduled 9 a.m. time, rather than the actual time of 7:30 a.m. This was confirmed through interviews and record reviews with facility staff, including the infection preventionist, registered nurse, and director of nursing, all of whom stated that the facility policy requires medications to be administered and documented within one hour of the scheduled time and immediately after administration. The LVN stated that the decision to administer all morning medications together at 7:30 a.m. was based on personal preference and the resident's unpredictable willingness to take medications at different times, rather than following physician orders or facility policy. The facility's policy also requires that any changes to medication administration times be approved by the physician, and that all medication administration be documented immediately after giving the medication. The failure to follow these procedures resulted in a deficiency related to pharmaceutical services, specifically in the accurate administration and documentation of medications.