Failure to Meet Professional Standards in Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice in several areas, as evidenced by observations, interviews, and record reviews. For one resident with hypertension and heart failure, there were multiple instances where a prescribed medication, eplerenone, was not administered as scheduled. The Medication Administration Record (MAR) showed blank entries and missed doses without corresponding documentation or progress notes explaining the omission. The resident was not promptly informed about the unavailability of the medication, and there was a lack of timely communication with the provider and pharmacy regarding the medication's status. Staff interviews confirmed that documentation and resident notification were not completed as expected. Another resident, who was cognitively intact, was found to have three melatonin pills in their dresser drawer, despite documentation indicating the medication had been administered on six nights. This indicated that the resident had not taken the medication as intended on three occasions. Staff interviews revealed that the expectation was for nurses to observe residents taking their medications and ensure they had fully swallowed them before leaving the room, which did not occur in this case. Additionally, during a medication cart review, an insulin pen was found in a medication cart without an open date labeled, as required by facility policy. Staff confirmed that insulin pens are to be dated when first used, and the absence of a date meant the insulin could not be verified as safe for use. These failures in medication administration, documentation, and storage practices did not meet professional standards and placed residents at risk.