Failure to Administer and Document Ordered Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medications for one resident. Multiple instances were identified where ordered medications were not administered as scheduled, as evidenced by blank entries on the Medication Administration Record (MAR) for various dates. The missed medications included Levothyroxine, Calcium Carbonate, Cyclosporine drops, Tizanidine, Lyrica, Ativan, Atorvastatin, Toprol, Ramelteon, Ropinirole, Duloxetine, Entresto, and Topiramate. The MARs did not contain documentation or reasons for the missed doses, contrary to facility policy, which requires documentation if a medication is withheld, refused, or not given at the scheduled time. The resident involved was a female with diagnoses including acute and chronic respiratory failure with hypoxia, type 2 diabetes, and hypothyroidism. She required maximal assistance with most activities of daily living and had an intact cognitive status. Her care plan included interventions to administer medications as ordered for conditions such as hypothyroidism, restless leg syndrome, chronic pain, neuropathy, anxiety disorder, and other chronic conditions. During interviews, the resident reported increased pain levels when medications were missed, although she was unsure which specific medications were not received. Staff interviews revealed a lack of awareness or recall regarding the missed medications. Nursing and medication aide staff stated that any held or refused medications should be documented in the MAR and a progress note made, but the MARs reviewed showed unexplained blanks. The Assistant Director of Nursing acknowledged ongoing issues with staff accountability and documentation, and administrative staff were unaware of the specific missed medications but confirmed that the expectation was for medications to be administered as ordered. The facility's policy requires safe, timely administration of medications and proper documentation when medications are not given.