Late and Undocumented Medication Administration by Med Aide
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate and timely administration and documentation of medications for a resident. The resident had diagnoses including hypotension, hypertensive heart disease with heart failure, atherosclerotic heart disease, and type 2 diabetes, and was prescribed Dapagliflozin, Metformin, Midodrine, and Pantoprazole, among other medications. On the survey date at 10:18 AM, Med Aide B checked the resident’s blood pressure with a wrist cuff, obtaining a reading of 104/46, and then prepared the resident’s 8 AM and 9 AM medications together in a small cup. At 10:24 AM, Med Aide B administered six pills, including Dapagliflozin 5 mg, Pantoprazole 40 mg, Metformin 1000 mg, and Midodrine 10 mg, well outside the facility’s policy window for 8 AM medications. Review of the Medication Administration Record (MAR) for that month showed the 8 AM medications documented as given by Med Aide B without any notation that they were administered late. The electronic record contained no note indicating late administration. In an interview, Med Aide B acknowledged that the 8 AM and 9 AM medications were given late and stated he understood medications were to be given within one hour before or after the scheduled time, but he did not notify the nurse or document the late administration and reported he was unaware of how to document late medications in the electronic system. The DON stated she expected medications to be administered within the one-hour window on the MAR, noted that Pantoprazole should have been given prior to breakfast and that the resident had already eaten by the time it was administered, and indicated that the charge nurse should be notified when medications are not given on time. Facility policy required medications to be administered within one hour of the scheduled time and required circled initials and explanatory notes on the MAR when medications are given at other than the scheduled time, which was not followed in this case.
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