Failure to Administer and Accurately Document Medications for Two Residents
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two out of three sampled residents, as evidenced by missed and improperly documented medication administration. For one resident with complex medical conditions including anoxic brain damage, epilepsy, and chronic respiratory failure, the Medication Administration Record (MAR) showed multiple instances where scheduled medications were not documented as given. These included antiseizure medications, muscle relaxants, supplements, and other critical drugs. Additionally, the MAR indicated that several medications were documented as administered on dates when the resident was not present in the facility, having been transferred to an acute care hospital. Interviews with facility staff, including an LVN and the DON, confirmed that blank spaces on the MAR indicated medications were not administered, and that check marks were used to indicate administration. The DON verified that the resident was not in the facility during the times some medications were documented as given, confirming inaccurate documentation. The facility's policies required medications to be administered as prescribed and for staff to accurately document administration or reasons for withholding medications, which was not followed in these cases. A second resident, with diagnoses including epilepsy and carotid artery stenosis, also had missing documentation for scheduled medications on specific dates. These included artificial tears, blood thinners, supplements, and antihypertensive medications. The DON confirmed that the MAR lacked evidence of administration for these medications and acknowledged that blank spaces meant the medications were not given. The failures in medication administration and documentation were verified through medical record review and staff interviews.