Failure to Accurately Administer and Document Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident with multiple diagnoses, including type 2 diabetes, hyperlipidemia, COPD, hypertension, seizures, and cerebral infarction. On three separate occasions, medications were not administered as ordered: Lamotrigine was given in an incorrect dose on two occasions, and Pregabalin was not properly documented or possibly not administered on another occasion. Medication administration records (MAR) and controlled drug administration records (CDAR) showed discrepancies between what was signed off and what was actually given, with staff unable to confirm whether medications were administered as documented. Interviews with nursing staff revealed confusion and lack of adherence to proper medication administration procedures. One nurse followed handwritten instructions from a family member rather than the physician's order on the medication bottle and MAR, resulting in the resident receiving only half the prescribed dose of Lamotrigine. Another nurse signed off on the MAR for Pregabalin but could not confirm if the medication was actually given, and there was no corresponding entry on the CDAR. Staff also failed to report these medication errors to the Director of Nursing (DON) as required by facility policy. The facility's administration and medical director were unaware of the medication errors until informed by the surveyor. The facility's policy required staff to verify medication orders against the MAR and to report any medication errors immediately, but these procedures were not followed. Documentation and communication lapses contributed to the errors, and there was no evidence that the errors were identified or addressed by staff prior to the survey.