Failure to Administer and Document Prescribed Medications and Enteral Feedings
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident with multiple complex medical conditions, including a history of traumatic subdural hemorrhage, epilepsy, and seizure disorders. Record review revealed that the resident did not receive several prescribed medications and enteral feedings on multiple occasions, as evidenced by blank spaces in the electronic Medication Administration Record (eMAR) for various dates. The medications not administered included a nicotine patch, folic acid, a multivitamin, vitamin B1, docusate sodium, levetiracetam, Tylenol, and enteral nutrition, all of which were ordered by the physician and documented in the resident's care plan and medical orders. Interviews with nursing staff, including charge nurses and the DON, confirmed that blank entries in the eMAR indicated that medications were not administered, constituting medication errors and poor quality of care. Staff acknowledged that it was their responsibility to ensure proper documentation and administration of medications, and that failure to do so could result in the resident not receiving necessary treatment. The administrator and nurse managers also stated that they were ultimately responsible for ensuring accurate documentation and that if it was not documented, it was not done. The facility's own policies on medication administration and refusal of treatment require that medications be administered as prescribed and that any refusals or omissions be thoroughly documented, including the reason for refusal, the resident's response, and notification of the physician. However, there was no documentation in the medical record to indicate that the resident refused the medications or that the physician was notified of missed doses. The lack of documentation and administration of prescribed medications and enteral feedings represents a failure to meet the pharmaceutical needs of the resident as required by facility policy and regulatory standards.