Failure to Manage Narcotic Medications and Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to appropriately manage narcotic medications and ensure medications were administered as ordered by a physician. In one instance, a resident with a prescription for Oxycodone had their dose changed from 15mg to 7.5mg every 8 hours. The medication administration record showed that half-tablet doses were given, but there was no documentation of the required wasting of the unused half-tablets, as mandated by facility policy and federal regulations. Staff interviews confirmed that narcotics should not be split unless immediately wasted with two nurses' signatures, and the facility's own policy required documentation of both the administered and destroyed portions of controlled substances. Additionally, the facility failed to provide ordered medications to several residents due to unavailability. Multiple medications, including Calcium Citrate, Listerine Mouthwash, Potassium Chloride, Trelegy Ellipta, and Fish Oil, were not administered as ordered over several days. Documentation in the medical records indicated that these medications were unavailable, but there was no evidence that the pharmacy or the prescribing physician was notified about the missing medications, as required by standard practice. Staff interviews revealed that when medications were unavailable, the process was to document the issue and inform the nurse, who was then responsible for contacting the pharmacy and physician. However, in these cases, there was no documentation that such notifications occurred. The Director of Nursing confirmed the expectation that the pharmacy and physician should be contacted when medications are unavailable, but this was not reflected in the records reviewed during the survey.