Failure to Administer Parkinson's Medication Timely and Maintain Medication Cart Standards
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, specifically by not ensuring the timely administration of medications and by not maintaining medication storage standards. For one resident with a diagnosis of Parkinsonism, the facility did not administer Carbidopa/Levodopa (both ER and IR formulations) within one hour of the scheduled times on numerous occasions, as documented in the Medication Administration Records. This medication is critical for controlling tremors and other symptoms associated with Parkinsonism, and the resident reported experiencing increased tremors when doses were delayed. The resident confirmed that late administration of her medication made it difficult for her to complete daily tasks, and observations corroborated the presence of tremors when medications were not given on time. Interviews with the Interim DON and the resident further established that the facility was aware of the importance of timely medication administration for Parkinson's Disease and related disorders. The Interim DON acknowledged that all medications should be administered within one hour of the scheduled time and that delays in administering Carbidopa/Levodopa could result in worsening symptoms such as tremors, rigidity, and pain. Despite this, there was no evidence that the facility had reviewed the records to determine the frequency or extent of late medication administration for this resident. Additionally, the facility failed to ensure that medication carts were free of expired medications. During an inspection of the 200 Hall Med Aide Cart, an expired, open, and in-use bottle of Aspirin 325 mg was found. Staff interviews confirmed that nursing staff are expected to check carts daily for expired medications, and that expired medications can lose potency and efficacy. The presence of expired medication on the cart indicated a failure to follow established procedures for medication storage and safety.