Failure to Administer and Document Scheduled Medications
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for four residents. On the night in question, the agency night nurse, an LPN, reportedly slept through most of her shift and did not complete wound treatments or document medication administration in the Electronic Medication Administration Record (EMAR). As a result, there was no documentation that several residents received their scheduled early morning medications, including a range of drugs such as Amantadine, fluoxetine, lactulose, omeprazole, baclofen, buspirone, diazepam, levetiracetam, Norco, fluticasone, omeprazole, aspirin, finasteride, furosemide, lidocaine patch, trelegy inhalation, venlafaxine, doxycycline, Eliquis, metformin, metoprolol, oxybutynin, gabapentin, baclofen, escitalopram, scopolamine patch, tizanidine, Colace, famotidine suspension, Lyrica, trihexyphenidyl, and propranolol. The lack of documentation made it unclear whether the medications were administered as ordered. The Director of Nursing confirmed that if there is no documentation in the MAR, the facility would typically check medication cards to determine if medications were given, but this was not done in this instance. The medication cards for the relevant period were not available for review, and the charting system's shift changeover may have prevented the next nurse from noticing missed doses. The facility's policy requires immediate documentation after medication administration, which was not followed in these cases.