Failure to Identify and Document Medication Administration Omissions
Penalty
Summary
The facility failed to maintain an effective and accurate system for identifying and correcting medication administration documentation omissions for physician-ordered medications. Multiple residents had numerous undocumented medication administrations, with no explanations or reasons recorded in the medication administration records (MARs) or nursing notes. The omissions included a wide range of medications, such as antipsychotics, insulin, pain medications, and supplements, and in some cases, checks for controlled substances like fentanyl patches were not documented. Facility policy required that such omissions be identified and addressed as medication errors, but this was not done. A review of the records for 14 out of 17 sampled residents revealed repeated instances of missed medication administrations and undocumented medication checks. For example, one resident had ten missed doses of various medications, another had 25 missed administrations, and another had 59 undocumented fentanyl patch checks. In all cases, there was no documentation to explain why the medications were not administered, and the medical records did not address the errors or any potential outcomes. Staff interviews confirmed that the process for identifying and documenting these omissions was not followed, and staff responsible for pharmacy services did not consider undocumented administrations as medication errors unless specifically reported or related to narcotics discrepancies. The contracted pharmacy also failed to identify or address these ongoing concerns. Staff interviews indicated a lack of clarity regarding who was responsible for reviewing MARs for missed doses or documentation holes. Facility policies clearly defined medication omissions as errors and required immediate documentation and follow-up, but these procedures were not implemented, resulting in unaddressed medication errors for a significant number of residents.