Failure to Administer Medications According to Physician Orders and Facility Policy
Penalty
Summary
Facility staff did not ensure that a resident received medications in accordance with professional standards of practice and facility policy. The facility's policy requires staff to verify and administer medications at the correct time, dose, route, and for the correct resident. However, review of the electronic medication administration record (e-MAR) revealed multiple instances where medications, including artificial tears, Biotene oral rinse, escitalopram, levothyroxine, pregabalin, Restasis eye drops, and ziprasidone, were administered significantly later than their scheduled times or not administered at all. For example, artificial tears scheduled for 8:00 a.m. were given at 12:34 p.m., and levothyroxine scheduled for 6:00 a.m. was not documented as administered on two consecutive days. These delays and omissions in medication administration were identified through a review of the clinical record and facility policy. The findings indicate that the resident did not consistently receive medications as ordered, which is not in accordance with the facility's established procedures and professional standards of practice.