Failure to Administer and Accurately Document Bedtime Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services and medication administration met professional standards of quality for one resident. The resident had diagnoses including anxiety disorder, major depressive disorder, schizophrenia, a history of pulmonary embolism, and transient ischemic attack, and was on anticoagulant therapy with a care plan that required medications to be administered as ordered and monitoring for side effects. The resident also received psychotropic medications for depression, anxiety, tardive dyskinesia, and fibromyalgia, with care plan interventions to administer medications as ordered, monitor effectiveness, and update the medical provider as needed. On an evening in November, the resident did not receive all of their ordered bedtime medications. The electronic Medication Administration Record showed multiple medications scheduled at bedtime, including Buspirone, Caplyta, Eliquis, Floranex, Lipitor, Lyrica, Oxycodone, Polyethylene glycol, Senna S, Simethicone, Topiramate, Valbenazine, and Zyrtec. LPN #3 signed all of these medications as administered, but later stated that only the narcotics and stock medications were actually given because the other evening medications were not in the medication cart. Statements from staff and the facility’s investigation indicated that a new 7‑day supply of pill packs for the resident was in the medication room and had not been placed into the medication cart, and that LPN #3 either did not recognize or did not use these pill packs to administer the remaining medications. The facility’s records and interviews showed that LPN #3 did not notify the nursing supervisor, pharmacy, or the medical provider that the resident’s evening medications were unavailable and omitted, and there was no documentation in the progress notes that the medications were unavailable or that a provider was consulted for new orders. The resident later reported to staff that they had not received their evening medications and complained of increased tardive dyskinesia symptoms, although nursing and the physician reported they did not observe increased symptoms at that time. The physician and pharmacy consultant both stated they were not aware of being notified about the omitted medications and emphasized that medications should not be documented as given if they were not administered. The facility’s policies required immediate and accurate documentation of medication administration, notation and reporting of withheld medications, and prompt notification of the physician when treatment needed to be significantly altered, but these requirements were not followed in this incident.
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