Failure to Administer Medications as Scheduled and Document Accurately
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident with Parkinson's disease and dyskinesia. The resident was prescribed Carbidopa-Levodopa and Buspirone to be administered three times daily. Record reviews showed that on multiple occasions, these medications were not administered within the scheduled time window, and in some cases, doses were either missed or documented as given without actual administration. Medication administration records indicated that staff administered the resident's morning medications late, outside the scheduled 7:00 a.m. to 10:00 a.m. window, and the noon doses were either not given or were documented as given close to the previous dose. Staff interviews revealed that the late administration was due to short staffing, and in some instances, staff marked medications as given on the Medication Administration Record (MAR) without actually administering them. Staff did not notify the physician or the Director of Nursing (DON) about the late or missed doses, nor about the documentation discrepancies. Further interviews with the Assistant Director of Nursing (ADON), DON, and the attending physician confirmed that medications should be administered within a specific time frame and that deviations should be reported. The facility's policy required medications to be administered safely, timely, and as prescribed, with staffing arranged to prevent interruptions. However, the facility did not ensure adherence to these procedures, resulting in the resident not receiving medications as scheduled.