Failure to Administer and Document Medications as Ordered
Penalty
Summary
A deficiency was identified when a resident with diagnoses including hemiplegia, hemiparesis, and an overactive bladder did not receive medications as prescribed by the physician. The resident's care plan included the administration of nystatin powder to specific areas of the body at designated times. Review of the Medication Administration Record (MAR) revealed that nystatin powder was not signed out as administered on several occasions, including missed doses for the abdominal fold and scrotum on specific dates. Interviews with nursing staff, including an LPN, RN/Unit Manager, and the Director of Nursing, confirmed that medications should be administered according to physician orders and documented on the MAR. All staff interviewed stated that if a medication was not signed out on the MAR, it indicated the medication was not given. The facility's policy on administering medications, revised in March 2019, requires that medications be administered in a safe and timely manner as prescribed. The failure to administer and document the administration of nystatin powder as ordered for the resident constituted a violation of both facility policy and state regulations. The deficiency was substantiated through record review, staff interviews, and review of facility policies.