Failure to Adhere to Professional Standards in Medication Administration
Penalty
Summary
Surveyors identified that the facility failed to adhere to professional standards of practice in medication administration for multiple residents. One resident reported ongoing concerns about medications being administered late, which was confirmed by a review of the medical record showing that several scheduled morning medications, including those for hypertension, COPD, atrial fibrillation, and bowel regimen, were documented as given over two hours past the scheduled time. Another resident's medication administration audit revealed that numerous morning medications, including those for pain management, nerve pain, hypertension, asthma, GERD, and wound support, were also administered significantly later than scheduled, with some medications given several hours late. The Director of Nursing acknowledged these delays and attributed some of the issues to agency nurses not documenting medication administration at the time it occurred, despite the facility's standard practice requiring real-time documentation. Additionally, during a medication administration observation, an LPN was seen preparing and bringing scheduled medications into a resident's room while the resident was receiving morning care. During this process, one pill was dropped onto the bed, and the nurse left the room to retrieve a replacement, leaving the cup with the prepared medications unattended on the bedside table. The nurse admitted that leaving pre-poured medications unattended was not the accepted standard of practice. The DON confirmed that medications should never be left unattended and that the standard is to sign off medications at the time of administration. These findings were based on resident interviews, direct observation, and medical record reviews, and were discussed with the facility's administration team. The deficiencies involved both the timing of medication administration and the improper handling of medications during administration, affecting residents with complex medical needs such as hypertension, COPD, atrial fibrillation, pain management, and wound care.