Failure to Ensure Medication Availability, Timely Administration, and Secure Storage
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered, and that medications were stored securely for multiple residents. Several residents did not receive their prescribed pain medications, such as hydrocodone-acetaminophen, gabapentin, and Lyrica, for extended periods due to issues with prescription processing, pharmacy supply, and lack of authorized prescribers for controlled substances. Documentation showed that residents experienced untreated pain, with pain assessments indicating moderate to severe pain levels during periods when medications were not available or administered. Staff interviews confirmed that residents were left without their pain medications for up to a week, and alternative medications like acetaminophen were ineffective in relieving their pain. In addition to pain medications, other routine and critical medications, including insulin and diuretics, were administered late on multiple occasions. Medication administration records and audit reports documented numerous instances where medications were given hours after the scheduled time. Staff attributed these delays to high workloads, interruptions during medication passes, agency staff unfamiliarity, and technical issues with electronic systems. Residents and staff reported that late administration was a recurring issue, particularly when agency nurses were on duty, and that this affected the timely management of conditions such as diabetes and heart failure. The facility also failed to maintain secure storage and administration of medications. Observations and staff interviews revealed that medications were left unattended on medication carts, in resident rooms, and in common areas such as the dining room. Medications were sometimes left for residents to self-administer without proper orders or assessments for self-administration capability. Facility policies and pharmacy procedures required medications to be stored securely and not left unattended, but these protocols were not consistently followed, as confirmed by multiple staff and resident accounts.