Failure to Administer and Document Medications per Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its policies and procedures for timely medication administration and proper documentation for three of five sampled residents. The facility’s policies required medications to be administered within one hour before or after the scheduled time and documentation to occur immediately after, and never before, administration. Review of the Medication Administration Audit Reports showed that multiple medications scheduled for 9:00 AM for three residents were documented as given at times outside the required one-hour window, and a nurse later admitted to pre-signing the MARs before actually administering the medications. One resident with alcoholic cirrhosis with ascites and diabetes, cognitively intact but dependent for most ADLs, had several 9:00 AM medications (including metolazone, furosemide, gabapentin, lactulose, rifaximin, midodrine, and spironolactone) documented as administered between 9:38 AM and 9:41 AM. Another cognitively intact resident with diabetes and heart disease, requiring maximal assistance with dressing and toileting hygiene, had 9:00 AM medications (ferrous sulfate, diltiazem, metoprolol, and hydralazine) documented as administered between 9:30 AM and 9:31 AM. A third resident with sequela of cerebral infarction and moderately impaired cognition, requiring supervision for most ADLs, had 9:00 AM medications (amlodipine and clopidogrel) documented as administered at 9:27 AM and 9:28 AM. During observation and interviews, an LVN was seen at the medication cart well after the scheduled 9:00 AM medication time and stated that the 9:00 AM medications for the three residents in the same room had not yet been administered. The LVN later confirmed that on that date she was late in administering the medications and had pre-signed the MARs for those residents before actually giving the medications, acknowledging that this was not the facility’s practice. A resident also reported that medications were sometimes not administered on time and that this depended on which nurse was working, noting that medications were especially late on the night shift. A registered nurse confirmed that the standard was to “pour, pass, and sign,” and that medications must be given as ordered within the one-hour before/after window, consistent with the written policies reviewed by surveyors. The report states that this deficient practice resulted in delayed medication administration for the three residents and had the potential for residents’ health to be compromised.
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