Failure to Administer Medications per Physician Orders and Inadequate Monitoring
Penalty
Summary
The facility failed to ensure that medications were administered per physician orders and did not assess or monitor for potential medication interactions and adverse effects. Two residents with intact cognition and multiple diagnoses, including diabetes, bipolar disorder, schizophrenia, and hypertension, were found to have received or potentially received Tylenol PM without a physician order. Review of medical records showed that neither resident had an order for Tylenol PM during the period in question, yet staff statements and interviews indicated that an LPN was observed pre-pouring Tylenol PM and Melatonin into medication cups for multiple residents, regardless of whether there was a physician order. Multiple staff members reported witnessing the LPN preparing and distributing Tylenol PM to residents without verifying current orders. Statements revealed that the LPN routinely pre-poured medications, including Tylenol PM, and placed them in medication cups before checking for new orders. The LPN admitted to preparing the medications in advance for convenience and stated that any unused Tylenol PM was returned to the bottle at the end of the medication pass. However, other staff and resident interviews indicated that some residents did receive Tylenol PM, with at least two residents recalling being given two Tylenol PM tablets, which was not in accordance with any physician order at the time. The facility's investigation into the incident was incomplete. There was no documentation of pharmacy notification, resident assessments, or monitoring for adverse reactions. Not all potentially affected residents or staff were interviewed, and there was no evidence of systematic monitoring or assessment following the allegations. The facility's own policy required medications to be administered only after confirming orders and to observe and document resident reactions, but these procedures were not followed. The incident was not reported to the state agency as required, and the lack of thorough investigation and documentation was confirmed by the current DON and Administrator.