Failure to Administer Prescribed Medications as Ordered
Penalty
Summary
The facility failed to ensure the provision of pharmaceutical services to meet the needs of a resident by not administering multiple prescribed medications over several days. According to the resident's Medication Administration Records (MARs) for September and October, there were multiple instances where essential medications, including a blood pressure medication (Amlodipine), a thyroid medication (Levothyroxine), a pain medication (Gabapentin), a medication for GERD (Pantoprazole), and a potassium supplement (Potassium Chloride), were not administered as ordered. The MARs showed blanks on specific dates, indicating missed doses, which was confirmed by both an LPN and the Nursing Home Administrator during interviews. Both staff members acknowledged that blanks on the MAR meant the medications were not given, constituting medication errors. The resident involved had diagnoses including hypertension, hypothyroidism, GERD, and hypokalemia, and was cognitively intact according to a recent assessment. The resident's care plan and physician orders specified the need for these medications to manage their conditions. Facility policy required medications to be administered according to physician orders and for staff to ensure accurate documentation and administration. Despite these policies, the resident did not receive their prescribed medications on at least five days across two months, as evidenced by the MARs and staff interviews.