Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of medication administration for multiple residents, as evidenced by direct observations, interviews, and medical record reviews. One resident was given Metformin despite a physician's order to hold the medication for two days following a procedure. The resident reported that the nurse left the medication in the room without ensuring it was taken and also left an insulin pen labeled for another resident. The same nurse was previously documented for attempting to administer Metformin when it was not scheduled and for administering another resident's insulin to the wrong individual. A review of medication administration records (MARs) for several residents revealed a consistent pattern of late documentation and possible late administration of medications. Medications such as Gabapentin, Hydralazine, Acetaminophen, Aspirin, Eliquis, Phenytoin, Amlodipine, chlorhexidine gluconate, and Humalog insulin were frequently signed off hours after the scheduled administration times. In many cases, it was unclear whether the medications were actually given late or if the documentation was completed later in the shift, raising concerns about the accuracy and timeliness of medication administration and record-keeping. Interviews with nursing staff confirmed that medications were sometimes administered or documented outside the required one-hour window due to workload and staffing issues. Staff acknowledged that when a medicine aide was unavailable, nurses were responsible for a higher number of residents, which led to delays in both medication administration and documentation. Facility leadership agreed that these practices were a concern and did not meet professional standards of quality.