Medication Administration Errors and Missed Medical Appointments Due to Lack of Transportation
Penalty
Summary
The deficiency involves the facility’s failure to meet professional standards of practice for medication administration and transportation to medical appointments for three residents. One resident with ESRD, dependence on renal dialysis, and type 2 DM with neuropathy had physician orders for gabapentin three times daily for anxiety, crying, and insomnia; atorvastatin 40 mg at bedtime; and Protonix 40 mg at bedtime. The MAR for this resident showed these medications, scheduled for 8:00 pm, were not administered until midnight. The resident reported to the day shift nurse that the night nurse did not give the 8:00 pm medications until midnight, and the UM and DON confirmed the medications were not administered as ordered on that date. Another resident with ESRD, dependence on renal dialysis, type 2 DM with neuropathy, and polyneuropathy had physician orders for gabapentin 100 mg at bedtime for neuropathy, Remeron 30 mg once daily for depression and appetite, and Tylenol 325 mg three times per day for pain. The MAR indicated these medications, scheduled for 9:00 pm, were documented as administered at midnight. The resident informed the day shift nurse that the night nurse did not give the 9:00 pm medications, and reiterated during a care plan meeting that no medications were administered during that night. The UM confirmed the resident did not receive the night medications as ordered, and the Administrator stated the night shift nurse admitted the medications were not administered despite being marked as given on the MAR. The DON confirmed that, on the night in question, one resident received medications late and the other did not receive ordered medications at all, although they were documented as administered. The facility also failed to consistently provide transportation for scheduled medical appointments. One resident, who had a follow-up appointment related to recent eye surgery, was observed waiting at the front door with a CNA and the UM for transportation to an 8:30 am appointment. The UM later confirmed that this follow-up appointment was canceled because no transportation was available. The report also references additional missed appointments for two other residents, including dialysis appointments, due to lack of transportation. A physician stated his expectation that residents should not miss appointments, including dialysis, due to transportation issues and confirmed that such missed appointments had occurred at the facility.
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