Failure to Ensure Accurate Medication Administration and Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquisition, receipt, dispensing, and administration of all drugs and biologicals for a resident with complex medical needs. The resident, a female with diagnoses including Type 1 diabetes mellitus with ketoacidosis, altered mental status, urinary tract infection, and severe cognitive impairment, was prescribed multiple medications to be administered via G-tube and orally. Record reviews revealed inconsistencies in the administration of medications, particularly phenytoin and PEG 3350, with documentation showing missed doses and refusals. Hospital records indicated the resident had extremely low phenytoin levels, and imaging showed significant fecal impaction, suggesting that prescribed medications for seizure control and constipation were not consistently administered as ordered. Interviews with facility staff, including nurses and certified medication aides, revealed that the resident sometimes refused medications, and staff would attempt re-administration, notify charge nurses, and document refusals. However, hospital physicians noted that the resident's phenytoin levels were subtherapeutic, and imaging findings were consistent with a lack of regular administration of prescribed laxatives. The facility's medication administration records did not consistently reflect that all medications were given as ordered, and there were discrepancies between staff statements and documented administration. Further review of the facility's policies indicated that licensed nurses are required to know the indications, dosages, and documentation requirements for all medications administered. Despite this, the resident's medication records showed missed doses and lack of administration for certain medications, particularly during periods when the resident was not hospitalized. The failure to ensure accurate and consistent medication administration was corroborated by both facility documentation and hospital findings.