Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice for several residents. For one resident, aspirin prescribed as a stroke prophylaxis was administered outside the one-hour window specified by the physician's order, with documentation showing the medication was given over two hours late. Both the licensed nurse and the Director of Nursing acknowledged the importance of timely administration and adherence to physician orders, as outlined in facility policy. Another resident received Fluticasone nasal spray for allergies, but the administration did not follow the manufacturer's instructions. The nurse instructed the resident to tilt her head back instead of forward, contrary to the packaging insert. Both the nurse and the Director of Nursing confirmed that following manufacturer guidelines is necessary for medication effectiveness, and the nurse admitted to not following the correct procedure during administration. A third resident with a G-tube did not have proper placement verification before medication administration, as the nurse used water instead of air for auscultation and administered medication using a syringe/plunger rather than by gravity, which is against facility policy. Additionally, for two other residents, controlled medications could not be accounted for due to discrepancies between the controlled drug record and the electronic medication administration record. The nurses and Assistant Director of Nursing confirmed that documentation was incomplete and that required audits and reconciliations were not performed, as required by facility policy.