Widespread Failure to Administer and Document Physician-Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications and treatments were administered and documented in accordance with physician orders and the facility’s own medication administration policies. Facility policies required that all physician orders be complete and accurately transcribed to the MAR/TAR, that medications be administered as prescribed, and that the individual administering the medication document administration directly after giving the dose, including circling and explaining any withheld, refused, or unavailable doses. Resident council minutes documented resident concerns that medications were not being received timely and that doses were being missed. Multiple residents with significant medical conditions had numerous blank entries on their MARs where ordered medications and treatments should have been documented. One cognitively intact resident with diagnoses including heart failure, morbid obesity, anxiety, chronic pain, and hypertension had repeated blank MAR entries for Eliquis, Lasix, potassium chloride, famotidine, ondansetron, gabapentin, Miralax, Tylenol, vitamins, artificial tears, Senna Plus, and a lidocaine patch, among others. This resident reported not receiving medications as ordered and specifically stated that missed gabapentin doses caused increased pain in the feet. Another cognitively intact resident with diabetes, stroke, hemiparesis, and depression had multiple undocumented pre-meal blood glucose checks and corresponding Novolog sliding-scale insulin doses, as well as missed or undocumented doses of long-acting insulin (Tresiba) and metformin, and reported not receiving insulin for several days and having a blood sugar over 200 when it was eventually checked. Additional residents with diabetes, dementia, chronic kidney failure, psychiatric diagnoses, atrial fibrillation, anemia, chronic pain, hypertension, COPD, Parkinson’s disease, seizure disorders, and other chronic conditions also had numerous blank MAR entries for ordered medications. These included missed or undocumented blood glucose checks and insulin doses, anticonvulsants (carbamazepine, Keppra), anticoagulants (Eliquis, aspirin), antihypertensives (metoprolol, carvedilol, amlodipine, hydrochlorothiazide), diuretics (Lasix), psychotropics (mirtazapine, quetiapine, trazodone, duloxetine, buspirone, hydroxyzine), Parkinson’s medications (carbidopa-levodopa, amantadine), COPD and inhaler therapies, eye drops, vitamins, supplements, antibiotics, and various GI and pain medications. For each of these residents, the MARs showed blank spaces without documentation that the medications were administered, held, refused, or otherwise accounted for, contrary to facility policy and professional standards of medication administration and documentation. Across the sampled residents, the pattern of blank MAR entries demonstrated that staff did not consistently administer or document physician-ordered medications and treatments as required. The failures encompassed time-sensitive medications such as insulin and antibiotics, chronic disease management medications, anticoagulants, anticonvulsants, and psychotropic agents. The report does not describe any contemporaneous documentation explaining the omissions, nor does it show that the required notations and explanatory notes were made when doses were not given. These inactions and documentation gaps, combined with resident reports of missed medications and elevated blood sugars, form the basis of the cited deficiency for not meeting professional standards of quality in medication administration and documentation.
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