Failure to Administer Scheduled Medications as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of seven residents, as evidenced by the omission of scheduled medication doses. Multiple residents did not receive their prescribed medications at the scheduled 5:00 pm administration time on various dates. Medication Administration Records (MARs) confirmed that medications such as antihypertensives, antiepileptics, antibiotics, antidepressants, and pain management drugs were not administered as ordered. Residents and their family members reported missed doses, and staff interviews revealed a lack of awareness or documentation regarding these omissions. Residents affected had a range of medical conditions, including gastroesophageal reflux disease, hypertension, diabetes, seizure disorders, depression, and chronic pain. Care plans for these residents included specific interventions requiring timely administration of medications to manage their conditions. Despite these documented needs, the MARs showed repeated failures to administer medications as scheduled, and in some cases, associated assessments such as blood pressure or pain level checks were also omitted. Interviews with medication aides (MAs) and the nurse practitioner (NP) indicated that there was no consistent system in place to monitor or report missed medication doses. The NP stated that missed doses were not communicated to her, and the DON acknowledged ongoing issues with medication administration, noting that a staff member responsible for one of the affected halls had been terminated for poor performance. The facility's own policy required medications to be administered within one hour of the prescribed time, but this standard was not met for the residents reviewed.