Failure to Administer and Accurately Document Scheduled Medications
Penalty
Summary
Surveyors identified a failure to ensure residents were free from significant medication errors when an agency LPN did not administer ordered medications as scheduled, despite documenting them as given. On the survey date around midday, the LPN reported she had already completed afternoon medications, and the manual medication administration record showed medications signed off. However, review of video footage between 10:45 AM and 11:40 AM showed the LPN at the nursing station, bathroom, medication room, and medication cart, but did not show her moving the cart to resident rooms, preparing medications, or entering resident rooms to administer medications, contrary to the facility’s medication administration policy requiring the cart to be moved close to residents before preparing and administering medications. One resident with diagnoses including diabetic polyneuropathy, osteoarthritis, and hemiplegia, and with intact cognition per MDS, reported in the afternoon that she had not received her scheduled dose of Gabapentin 800 mg ordered three times daily at 8:00 AM, 1:00 PM, and 5:00 PM. Another resident with diagnoses of COPD and acute and chronic respiratory failure, also cognitively intact per MDS, had an order for Combivent Respimat 20-100 mcg, one puff every six hours at 5:00 AM, 11:00 AM, 5:00 PM, and 11:00 PM. The evidence from resident report, EMR review, and video review showed that ordered medications for these residents were not administered as prescribed, despite being documented as given.
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