Failure to Administer Prescribed Medications and Inaccurate Documentation
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed for two residents. During a medication administration observation, an LPN was found to have placed two cups containing morning medications for two residents in the medication cart drawer after being unable to wake the residents to administer their medications. The LPN admitted to forgetting to return and administer the medications and had already documented in the electronic medical record that the medications had been given, despite not administering them. The Director of Nursing observed the cups and confirmed that medications should not be popped and left in the cart, and that not administering medications constitutes a medication error. One resident had multiple diagnoses including anemia, vitamin D deficiency, hypokalemia, psychotic disorder, dementia, chronic kidney disease, and diabetes, with a severely impaired cognitive status. The other resident had diagnoses such as malignant neoplasm of the lung, Alzheimer's disease, atherosclerosis, chronic heart failure, and chronic kidney disease, with intact cognition. Both residents were scheduled to receive several medications each morning, including critical medications such as blood thinners, cardiac medications, and Depakote sprinkles. The LPN did not notify the physician or nurse practitioner about the missed doses and did not document the omission in the residents' charts. Interviews with facility leadership confirmed that medications should not be left in cups in the medication cart and that any missed or late medication should be considered a medication error. The facility's policy requires medications to be administered as prescribed and any omission to be reported. The physician stated that missing certain medications, such as Depakote, could be significant and expects to be notified of any missed doses.