Multiple Failures in Medication Administration, Documentation, and Availability
Penalty
Summary
The deficiency involves multiple failures in pharmaceutical services, including improper administration of medications via gastrostomy tube (GT), incomplete controlled substance documentation, wrong medication administration, and lack of medication availability. For one resident with GT orders, a nurse crushed several medications (apixaban, Florastor, sennosides, and docusate sodium), mixed each with a small amount of water, and administered them sequentially through the GT without flushing between medications. The nurse also flushed the GT with only 10 ml of water before starting and did not flush with the ordered 50 ml of water before and after medication administration, contrary to the physician’s order specifying 50 ml pre- and post-medication flushes. The nurse later verified she had not followed the ordered flush volumes or flushed between medications, and the DON confirmed awareness of these findings. Another deficiency was identified in the handling and documentation of a controlled medication for a different resident. When the oxycodone 10 mg bubble pack was counted with a nurse, there were 25 tablets remaining, while the Narcotic and Hypnotic Record indicated 26 tablets should be left. The record showed one tablet removed at a specific time, and the MAR showed the resident received oxycodone twice that day at two documented times. The nurse confirmed that the nurse who removed and administered one of the oxycodone doses did not document the removal on the Narcotic and Hypnotic Record, and the DON verified these findings. Additional deficiencies included wrong-medication administration and failure to ensure availability of ordered pain medications. One resident, documented as capable and independent in decision-making, reported that a nurse repeatedly gave her the wrong medications; on one occasion she brought a pill to an RN, who identified it as calcium with vitamin D, while the resident’s order was for calcium only. The RN stated she informed the nurse involved that she must follow the physician’s order and not substitute what was available. In separate observations, two residents with orders for routine topical pain medications (voltaren gel for one resident’s right shoulder three times daily, and a daily lidoderm patch for another resident’s right shoulder) did not receive these medications because they were not available at the time of administration. Nurses stated the medications were out and that refills were being or had just been ordered, despite facility policy and DON expectations that routine medications be reordered several days before the supply is exhausted.
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