Failure to Administer and Document Prescribed Medications as Ordered
Penalty
Summary
The facility failed to ensure that pharmaceutical services were provided to meet the needs of a resident with gastrointestinal diagnoses, including hiatal hernia and gastroesophageal reflux disease with esophagitis. The resident had intact cognition and was prescribed aluminum-magnesium simethicone (Mylanta) and lidocaine oral solution to be administered at specific times before meals and at bedtime. Review of the Medication Administration Records (MAR) for August and September showed multiple instances where these medications were not administered as ordered, and there was no documentation that the physician was notified when the medications were unavailable or not given. Staff interviews and record reviews revealed that nursing staff did not consistently follow the MAR or the facility's medication administration policy, which required adherence to the Seven Rights of medication administration and prompt notification to the physician and pharmacy when medications were unavailable. One nurse reported not administering the lidocaine solution because it was not found and did not notify the physician, believing the medication was not pertinent. There was also confusion regarding the storage location of medications, leading to missed doses. The pharmacist confirmed that the medications were compounded and that the MAR required separate documentation for each, but this was not consistently done. The resident reported experiencing discomfort and bloating when the medications were missed, which affected their ability to breathe, eat, sit up, and walk. Facility leadership, including the Resident Care Manager and Director of Nursing Services, acknowledged that staff should have notified the physician and administered the medications as ordered. The deficiency was identified through observation, interview, and record review, and was found to be in violation of facility policy and regulatory requirements.