Medication Borrowing and Inaccurate MAR Documentation for Anticoagulant and Respiratory Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services and safe medication administration for a resident in accordance with physician orders and the facility’s “Six Rights of Medication Administration” policy. The resident was initially admitted and later readmitted with diagnoses including obesity due to excess calories, hyperlipidemia, and major depressive disorder, and had documented capacity to understand and make decisions. Physician orders dated 1/2/2026 included routine Ipratropium Albuterol inhalation solution via nebulizer every six hours for respiratory failure and Heparin 5000 units subcutaneously every eight hours for DVT prophylaxis, with the first Heparin dose to be taken from the Cubex automated medication system. Review of the Medication Administration Record for January 2026 showed that Heparin 5000 units was documented as last given on 1/2/2026 at 10 PM and Albuterol inhalation solution was documented as last given on 1/3/2026 at 12 AM. However, Cubex transaction reports from 1/2/2026 to 1/3/2026 indicated no medication transactions for this resident, and a pharmacy delivery receipt dated 1/3/2026 at 5:15 AM showed that multiple medications for the resident, including Ipratropium Albuterol solution and Heparin vials, were delivered but then returned to the pharmacy. This documentation pattern showed that the resident’s ordered medications were not obtained from the Cubex or from the resident’s own supply as intended. In interviews, one LVN stated she attempted to obtain Heparin from the Cubex during her 3 PM to 11 PM shift on 1/2/2026 but did not complete the process because it took too much time, and instead used a Heparin vial belonging to another resident who was receiving the same dose. She acknowledged she did not document that the Heparin administered came from another resident’s supply. Another LVN stated he did not actually administer Albuterol to the resident despite the MAR indicating it was given, explaining that he may have clicked “yes” on the MAR by accident and did not remember administering Albuterol or any other medications to the resident. These actions and documentation errors were inconsistent with the facility’s policy requiring the right resident, right time, right medication order, right dose, right route, and right documentation for medication administration.
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