Failure to Provide Medications and Maintain Controlled Substance Documentation
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for two residents, resulting in medication administration and documentation deficiencies. One resident, with diagnoses including high blood pressure and PTSD, was not administered prescribed Verapamil and Ambien medications during their stay. The resident reported that the facility did not provide these medications and was told a physician visit was required before administration. Medical record review confirmed that the medications were ordered but not given, and facility staff acknowledged the omission. For another resident, who had a history of a fall with a left lower extremity fracture and mild cognitive impairment, the facility did not maintain required controlled medication count sheets for administered Roxicodone and oxycodone. Although the medication administration records showed that these controlled substances were given as ordered, the corresponding count sheets were missing from the medical record. The Medical Records Director verified that these documents were not on file.