Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with physician orders and that medication administration was accurately documented for six out of seven residents reviewed. For one resident with a history of kidney transplant, the anti-rejection medication Tacrolimus was not administered on multiple occasions due to confusion over medication packaging and discrepancies in the medication cart. The nurse responsible signed the Medication Administration Record (MAR) as if the medication had been given, despite not administering it, which was later substantiated by low Tacrolimus levels in the resident. Other residents experienced similar issues with medication administration and documentation. One resident with quadriplegia did not have a controlled substance (Valium) properly documented as removed from the medication card, even though the MAR indicated it was administered, and there was no documentation for withholding the dose. Another resident with dementia had a dose of Ativan not documented as removed from the medication card, while the MAR showed it was given, with no supporting documentation for withholding. A resident with chronic pain was prescribed two tablets of Tramadol at bedtime, but only one tablet was documented as removed on several occasions, while the MAR reflected administration of two tablets, and there was no documentation for dose changes or omissions. Additionally, residents prescribed medications requiring pre-administration assessments, such as blood pressure checks for antihypertensive and orthostatic hypotension medications, did not consistently have these assessments performed or documented. In several instances, blood pressure readings from previous times or days were used to justify medication administration, or medications were held without documentation of the required assessment or rationale. These failures were confirmed by facility leadership and were not in accordance with facility policy or professional standards of nursing practice.