Failure to Administer and Monitor Medications According to Policy
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with its own policies and physician orders for two residents. For the first resident, who had multiple diagnoses including schizoaffective disorder, hyperlipidemia, major depressive disorder, and GERD, the facility did not administer eight scheduled morning medications within the required time frame. The medications, which included anticoagulants, antidepressants, antipsychotics, and other essential drugs, were due at 9AM but were not given until 11:03AM. The nurse confirmed that the medications were overdue and acknowledged that they should have been administered within one hour before or after the scheduled time. The resident also reported receiving medications late. For the second resident, who had diagnoses including benign prostatic hyperplasia, GERD, and chronic venous hypertension, the facility also failed to administer morning medications on time. The resident's 9AM medications were given at 10:30AM, and the nurse left the medications unattended on the resident's bedside table. The resident was observed taking the medications at 11:45AM, but the nurse admitted that the medications should not have been left unattended and that she did not observe the resident taking them. The DON confirmed that facility policy prohibits leaving medications unattended and requires nurses to observe residents taking their medications. The facility did not have any residents authorized to self-administer medications. The facility's policy and procedure on medication administration, last revised in July 2013, states that medications must not be prepared in advance or left unattended and must be administered within one hour before or after the scheduled administration time. Both the DON and the nurse involved acknowledged that these policies were not followed in the incidents involving the two residents.