Failure to Administer Medications as Prescribed and Improper Medication Management
Penalty
Summary
The facility failed to administer medications as prescribed for three residents, resulting in medication errors and improper medication management. For one resident with diagnoses including congestive heart failure, diabetes with neuropathy, and atrial fibrillation, the medication administration record showed that the resident received medications that were not prescribed to him. The resident identified the error after noticing differences in the appearance of the pills and reported the issue to the Business Office Manager, who found that the medications in the resident's possession actually belonged to his roommate. The Director of Nursing later confirmed that the medications administered and documented did not match the medications dispensed for each resident. Another resident, with chronic kidney disease, hemiparesis, hypertension, visual disturbances, and major depressive disorder, was also involved in the medication error. This resident could not recall which pills were administered but remembered being advised by his roommate not to take the pills as they were not his. The resident did recall receiving his eye drops. The Director of Nursing was informed that medications found in the first resident's possession did not belong to him, leading to the determination that the wrong medications were given to both residents. A third resident, diagnosed with metastatic breast and bone cancer, diabetes, hypertension, polyarthritis, and anxiety disorder, experienced an issue with the administration of a fentanyl patch. A nurse reported that the patch was nearly detached and not properly secured, and a replacement patch was not available until the following day, resulting in the resident being without the patch for approximately 12 hours. Additionally, it was confirmed that a CNA attempted to remove or cut the fentanyl patch, and conflicting documentation existed regarding the duration of the lapse in coverage.