Failure to Administer and Document Ordered Medications for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered medications as prescribed for residents with active treatment needs. One resident with a history of urinary tract infections and chronic kidney disease was ordered Bactrim DS 800-160 mg twice daily for a UTI over multiple 14‑day courses beginning in mid‑December. The MAR showed the initial dose was given, but subsequent scheduled doses on multiple mornings were either left blank or coded as “9 – Other/See Nurse Notes,” with progress notes repeatedly stating “awaiting delivery” of Bactrim. Despite this, new Bactrim orders with new start dates were entered several times, and there were repeated gaps where doses were not administered as ordered. On several dates, there was no corresponding nursing documentation explaining the non‑administration of the medication, even when the MAR indicated a code requiring a nurse note. A second resident, admitted with diagnoses including primary generalized osteoarthritis, cerebellar ataxia, pneumonia, and generalized muscle weakness, had a physician’s order for Cyanocobalamin (Vitamin B‑12) 1000 mcg IM daily for seven days for neuropathy. The MAR documented codes of “12 – Not Applicable” for two scheduled administration dates and a “9 – Other/See Nurse Note” on another date. However, the resident’s progress notes contained no documentation explaining the use of these codes or why the injections were not administered as ordered. The resident later reported feeling more fatigued than usual and believed she had not received all of her B‑12 injections, and stated that the facility was having problems obtaining the shots. Interviews and policy review further clarified the nature of the deficiency. The DON stated that when medications are unavailable, nurses are expected to document this on the MAR, notify the provider, and follow up with the pharmacy, and also noted that Bactrim was available in the facility’s automated medication dispensing system. For the B‑12 injections, the DON reported that the pharmacy had sent the medication in a kit and not all doses had arrived, and again stated that nurses should have contacted the physician and checked with the pharmacy when the medication was not available. Facility policies on Medication Monitoring and Medication Administration required that refusals, frequent holding of medications, adverse consequences, and discrepancies be reported and documented, but the records for both residents showed missing doses and incomplete or absent documentation related to those missed medications.
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