Failure to Administer Scheduled Medications Due to Staff Absence
Penalty
Summary
The facility failed to provide pharmaceutical services by not administering morning medications to 35 out of 72 residents on a specific date, resulting in 305 medication errors. The missed medication administration was due to a medication aide (MA) calling in sick after the shift had started and not coming to work. The MA notified the DON via text message early in the morning, but the DON did not inform anyone at the facility that the MA would not be present. As a result, no arrangements were made to cover the medication pass for the affected halls. Multiple staff interviews confirmed that the absence of the MA went unnoticed until late in the morning, at which point another MA was called in to pass medications. By then, the morning medication pass for two halls had been entirely missed. Nurses and other staff became aware of the situation only after residents had not received their scheduled medications. The medical director was notified and gave orders not to administer the missed medications but to monitor residents' vital signs for 12 hours and report any changes in condition. The incident was documented as medication errors for all affected residents. Resident records and staff interviews indicated that the residents involved had various significant medical diagnoses, including cerebral infarction, dementia, schizoaffective disorder, Huntington's disease, atrial fibrillation, and cancer. Progress notes and interviews confirmed that vital signs were monitored and no adverse outcomes were observed or reported at the time. The facility's own policy required medications to be administered in a safe and timely manner, with staffing schedules arranged to prevent interruptions, but these procedures were not followed in this instance.