Failure to Administer Medications as Ordered and Document Pain Assessments
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by physicians for four sampled residents. For one resident with severe cognitive impairment and multiple diagnoses, including diabetes and hypertension, gabapentin was ordered to be administered three times daily at specific times. However, medication administration records showed that doses were given significantly late on multiple occasions, outside the facility's policy of administering medications within one hour of the scheduled time. Another resident with diabetes and a recent knee replacement did not receive metformin as scheduled, with one morning dose administered over an hour late and a nighttime dose reportedly missed due to unavailability from the pharmacy. This resident also experienced unmanaged pain, as pain assessments were not documented in the medication administration record, and pain medication was not provided according to the physician's orders. Interviews with staff confirmed that pain levels were not consistently assessed or documented, and that medication administration was delayed or omitted when medications were not available. Additional residents with chronic conditions such as diabetes, hypertension, and epilepsy also experienced late administration of scheduled medications, including metformin, gabapentin, and hydrochlorothiazide. Medication administration records and staff interviews confirmed that medications were not given within the required timeframes, and documentation was not completed as per facility policy. Facility policies reviewed indicated that medications should be administered within one hour of the scheduled time and that pain assessments and documentation are required, but these protocols were not followed for the residents involved.