Failure to Administer and Report Missed Anti-Anxiety Medication Doses
Penalty
Summary
The facility failed to ensure that a resident received medication administration in accordance with physician orders, professional standards of practice, and the resident’s care plan. Specifically, over a two-day period, medication aides did not administer four out of five prescribed doses of alprazolam, an anti-anxiety medication, to a resident diagnosed with anxiety disorder and major depressive disorder. The medication administration record showed that the missed doses were documented as 'not available,' and the medication aides did not report these missed administrations to nursing leadership as required. The resident’s care plan indicated the use of anti-anxiety medication and outlined the need for monitoring for adverse reactions and safety concerns. Despite this, the medication aides failed to ensure the medication was available and did not follow procedures for reporting missed doses. One medication aide stated she verbally reported the missed doses to a charge nurse but did not document this communication, and the charge nurse denied receiving such a report. The facility’s policy required notification of supervisors and proper documentation when medications are not administered, which was not followed in this instance. The resident, who had moderate hearing difficulty and highly impaired vision, was unable to recall if all medications were received during the period in question. Interviews confirmed that the missed doses were not promptly reported or documented, and the medication was not reordered in a timely manner, resulting in the resident missing multiple doses of a critical medication.