Failure to Administer Scheduled Medications Due to Nursing Coverage Breakdown
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the omission of scheduled medications for six out of ten residents reviewed for pharmacy services. On a specific date, multiple residents did not receive their prescribed medications, including antihypertensives, antiepileptics, antipsychotics, anticoagulants, and other critical medications. The medication administration records for these residents showed blank entries for the morning medication pass, indicating that medications were not administered as ordered. Additionally, required blood pressure monitoring was not performed or documented for several residents. The deficiency was primarily caused by a breakdown in nursing coverage and communication. The scheduled day nurse failed to report for duty, and no replacement was assigned to cover the affected residents. The night nurse was directed to leave her shift, and the Administrator, who temporarily took over, did not complete the medication administration. Subsequent staff, including an LVN who started later in the morning, were not informed in a timely manner that they were responsible for the residents in question. By the time the new nurse became aware of her assignment, she determined it was too late to administer the missed morning medications. Multiple staff interviews confirmed that no nurse was assigned to administer medications to these residents during the critical morning window. The residents affected had complex medical histories, including hypertension, heart failure, seizure disorders, and schizophrenia, and many were dependent on G-tube medication administration. Observations confirmed that these residents were unable to reliably communicate about their care or recall if they had received their medications. The medication errors were not discovered until several days later during an external investigation. Staff did not notify physicians or families about the missed doses at the time of the incident, and the facility's leadership confirmed that the errors were not identified until after the fact.