Multiple Failures in Medication Administration, Documentation, and Controlled Substance Management
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of several residents, as evidenced by multiple deficiencies in medication administration, documentation, and controlled substance management. For one resident with type 2 diabetes and chronic pulmonary embolism, there was no documentation of the administration of Eliquis and insulin at a scheduled time, despite the nurse stating the medications were given. The nurse attributed the missing documentation to a computer error, acknowledging that such omissions could result in confusion about what medications had been administered. Another resident with dementia received divalproex sodium delayed-release tablets that were crushed prior to administration, contrary to pharmacy guidance and manufacturer instructions. The pharmacist was unaware that the medication was being crushed and indicated that this could affect the medication's absorption and effectiveness. The DON confirmed that the medication should not have been crushed and that the order was later changed to an appropriate formulation. Additionally, a resident with tardive dyskinesia did not receive multiple doses of Austedo XR due to the medication not being available in the facility, and the missed doses were not properly documented in the medical record. The DON and ADON were not aware of the missed doses until after the fact, and there was no formal process for confirming new medication orders in the electronic medical record, leading to further missed doses for other residents. The facility also failed to maintain accurate records for controlled substances. For one resident, two tablets of hydrocodone-acetaminophen could not be accounted for, and the facility's investigation was unable to reconcile the missing doses. The process for shift-to-shift narcotic counts was described, but discrepancies still occurred. In another instance, expired insulin vials for a resident with diabetes were found in the medication cart past the facility's policy for discarding opened insulin, and it was unclear if the expired insulin had been administered. The DON confirmed that insulin should be discarded after 28 days and that unlabeled insulin should not be administered.