Failure to Administer and Document Medications as Ordered for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to administer medications as ordered and failed to document administration for multiple residents. One resident with a history of traumatic cerebral hemorrhage, seizure disorder, dysarthria, anarthria, and dependence on tube feeding had multiple omissions or undocumented doses of famotidine, Keppra, and Baclofen across January and February. The Medication Administration Records (MARs) for this resident showed missing documentation for several scheduled doses of these medications on specific dates and times, and incident reports documented that staff discovered missed doses of Baclofen and Keppra for an evening shift and additional missed doses later in the month. Another resident with traumatic brain injury, traumatic brain dysfunction, quadriplegia, and severe cognitive impairment had missing documentation on the March MAR for ordered ipratropium‑albuterol nebulizer treatments via trach four times daily. A progress note documented that evening shift staff found the morning doses of glycopyrrolate and Baclofen still in the medication card, indicating they had not been given by agency staff. An incident report further documented that the facility attempted to contact the resident’s representative to update them about the missed medications. Staff interviews confirmed that nurses had found medications not given on prior shifts. A third resident with myotonic muscular dystrophy, diabetes mellitus, and malnutrition had a February MAR that indicated all bedtime medications were given on two consecutive days, but a subsequent health status note documented that staff later found evening and bedtime doses from one of those days still in the medication card. The missed medications included Midodrine, Eliquis, escitalopram, and quetiapine. An incident report described this as a medication event/missing medication. During interviews, the MDS coordinator acknowledged awareness that one resident had missed medications, and the DON acknowledged gaps on the MARs and stated that the facility followed the six rights of medication administration but lacked a policy directing staff how to administer medications.
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