Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
Facility staff failed to administer medications and treatments according to physician orders for three residents. For one resident, multiple doses of gabapentin, insulin glargine, and spironolactone were not administered as ordered, as evidenced by blank entries or notes such as "on order" or "pharmacy to send" in the electronic medication administration record (eMAR). The facility's Omnicell inventory indicated that these medications were available in stock at the time. Interviews with nursing staff confirmed that medications should be documented as given in the eMAR, and if not available on the cart, staff were expected to check the Omnicell stock. The facility's policy required medications to be administered as ordered by the physician. Another resident did not receive multiple prescribed medications, including atorvastatin, clopidogrel, Edarbyclor, Miralax, Mirapex, montelukast, gabapentin, magnesium oxide, and insulin lispro, during two evening medication passes. The medication administration record (MAR) was blank for these times, and there was no documentation in the nurse's notes explaining the missed doses. The resident's care plan included interventions to administer these medications as ordered for conditions such as hypertension, diabetes, hyperlipidemia, constipation, and pain management. Additionally, this resident did not receive wound care treatments for an abdominal wound as ordered every three days, with several missed treatments documented as blank on the treatment administration record (TAR) and no corresponding nurse's notes. A third resident did not receive melatonin as ordered for insomnia on multiple dates, as shown by blank spaces on the MAR. The facility's supply list confirmed that melatonin was available in-house. Nursing staff interviews indicated that if a medication was not on the cart, it should be obtained from the facility's stock or Omnicell. The executive director and other administrative staff were made aware of these concerns during the survey, and no further information was provided prior to exit.