Failure to Administer and Document Medications per Physician Orders and Facility Policy
Penalty
Summary
A deficiency occurred when a resident received an extra dose of Pregabalin (Lyrica) due to a breakdown in medication administration procedures. The resident, who had a history of narcotic dependence, osteoarthritis, joint replacement, spinal stenosis, neuropathy, and recent knee surgery, was prescribed Pregabalin 100 mg to be administered three times daily. On the day of the incident, a Medication Aide administered the scheduled dose and documented it appropriately. However, during the Medication Aide's lunch break, an LVN, who had been given the medication cart key, administered an additional dose of Pregabalin to the same resident without verifying the Medication Administration Record (MAR) or the Narcotic Count Sheet. The LVN subsequently filled out a medication waste form, indicating that the medication was wasted when, in fact, it had been administered to the resident. The Medication Aide signed the waste form without witnessing the medication being wasted, as required by facility policy. This misdocumentation was discovered after the resident reported receiving two doses of the same medication within a short time frame and provided video evidence from his room camera. Interviews confirmed that the LVN did not follow the required checks and that the Medication Aide signed documentation without proper verification. The facility's policy required that medications be administered according to physician orders, with proper documentation and verification, including the presence of two nurses when wasting medication. The failure to follow these procedures resulted in the resident receiving an unscheduled extra dose of medication and inaccurate documentation of medication handling. The incident was confirmed through interviews with the resident, staff, and review of video footage and records.