Failure to Administer and Document Medications as Ordered
Penalty
Summary
Facility staff failed to administer medications as ordered and failed to document reasons for holding medications for one cognitively intact resident with multiple chronic conditions, including hypertension, renal failure, hyperlipidemia, and a history of stroke. The resident’s physician orders in January included multiple daily and BID medications such as amlodipine, atorvastatin, cranberry, melatonin, pantoprazole, potassium chloride, spironolactone, thiamine, vitamin D3, cetirizine, apixaban (Eliquis), house shakes, gabapentin, and lactulose. Review of the January MAR showed numerous instances where these medications were marked as held on specific dates without any documented reason or corresponding physician orders to hold them. Similar issues continued in February, when gabapentin and spironolactone were held on several dates without documentation of the reason or evidence of new physician orders, and in March, when spironolactone and ondansetron were held without documented justification or physician authorization. During an interview, the CMT who documented the held medications stated they did not recall why the hold code was used multiple times for the resident and explained that, in practice, medications might be held if blood pressure was low, if residents had loose stools, or if they were not feeling well. The CMT further stated that whether the physician needed to be contacted depended on the reason for holding the medication, and that they believed they did not need orders to hold blood pressure medications or stool softeners even when no parameters were included in the original orders. The CMT reported not recalling notifying the physician about holding medications for this resident and acknowledged not documenting the reasons for holding them. The facility’s medication administration policy required medications to be administered as prescribed and for staff to contact the prescriber or physician if a dosage was believed to be inappropriate or associated with adverse consequences, but the records and interviews showed this process was not followed for this resident. Complaint #2799285
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