Failure to Administer Medications as Ordered and Lack of Required Documentation
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for three residents. One resident, admitted with congestive heart failure and adjustment disorder with depressed mood, did not receive multiple doses of her heart failure medication, antidepressant, and topical ointment for skin redness as documented in the Medication Administration Record (MAR). Another resident with Alzheimer's disease missed a scheduled dose of anti-fungal powder for moisture-associated skin damage. A third resident, diagnosed with recurring shoulder dislocation and psoriasis, did not receive her prescribed pain-relieving patch, topical cream for psoriasis, or her thyroid medication as ordered. Interviews and record reviews confirmed that the missed doses were not due to medication unavailability alone. The Infection Preventionist (IP) verified that the facility's emergency medication stock contained at least one of the missed medications, but it was not administered. Additionally, there was no documentation that the pharmacy or the physician was contacted regarding the missed doses, nor was there evidence of any instructions or alternative orders being recorded in the residents' charts. The acting Director of Nursing (DON) and the Administrator acknowledged that missing a medication dose constitutes a medication error and could negatively affect residents' health. The facility's policy requires medications to be administered according to prescriber orders and within required time frames, but this was not followed in these cases, as confirmed by the MARs and the lack of appropriate documentation or follow-up.