Widespread Failure to Administer Ordered Medications as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors when numerous ordered medications were not administered as prescribed to multiple residents on the same day. For one cognitively intact resident with alcohol abuse, depression, anxiety, HTN, and vitamin deficiencies, EMR and MAR review showed that ordered doses of hydrochlorothiazide and paroxetine were not given on the identified date, which the DON confirmed. Another resident with severe cognitive impairment, extensive ADL dependence, and complex cardiac, respiratory, renal, neurologic, and psychiatric conditions did not receive multiple ordered medications, including amlodipine, Nuedexta, carvedilol, Depakote Sprinkles, diazepam, levetiracetam, minoxidil, buspirone, and gabapentin on the same date, as verified by MAR review and the DON. Additional residents with significant neurologic, cardiac, respiratory, and nutritional diagnoses also did not receive ordered medications. One resident with anoxic brain damage, seizures, CHF, and gastrostomy status missed ordered doses of lactulose, levetiracetam, and valproic acid on the identified date, and the DON confirmed additional missed medications including omeprazole and clobazam. Another resident with prostate cancer, severe protein-calorie malnutrition, SVT, HTN, and urinary retention did not receive ordered doses of amlodipine, bicalutamide, and tamsulosin on the same date. A cognitively intact quadriplegic resident with COPD, asthma, epilepsy, HTN, and other comorbidities did not receive ordered doses of Anoro Ellipta, lisinopril, sertraline, levetiracetam, metoprolol, and baclofen during that day shift, which the DON also confirmed. Further review showed residents with DM2, COPD, HTN, anticoagulation needs, and psychiatric conditions missed critical medications, including anticoagulants and insulin. One resident with COPD, DM2, functional quadriplegia, and dementia did not receive ordered doses of apixaban, buspirone, carvedilol, metformin, and multiple doses of insulin aspart per sliding scale on the identified date. Another resident with COPD, DM2, HTN, schizoaffective disorder, seizures, and multiple other conditions missed numerous ordered medications, including antihypertensives, inhalers, psychotropics, diuretics, oral hypoglycemics, basal insulin, and multiple sliding scale insulin doses, as confirmed by the DON. A resident with post-stroke deficits and DM2 did not receive ordered sliding scale insulin doses at several scheduled times that day. Two additional residents with complex cardiopulmonary and psychiatric histories also experienced missed medications. One cognitively intact resident with COPD, major depressive disorder, generalized anxiety disorder, severe protein-calorie malnutrition, HTN, and bradycardia did not receive ordered morning doses of Coreg and minoxidil for HTN. Another resident with chronic respiratory failure, COPD, atrial fibrillation, HTN, BPH, depression, anxiety, and other comorbidities did not receive multiple ordered medications, including amiodarone, citalopram, Lasix, loratadine, a multivitamin, polyethylene glycol, vitamin D, Spiriva, Advair Diskus, apixaban, azelaic acid, tamsulosin, guaifenesin, buspirone, and ipratropium-albuterol on the identified date. The facility’s own Resident Agreement stated residents have the right to adequate and appropriate medical treatment and nursing care, and the facility’s medication administration policy required medications to be administered in accordance with professional standards of practice.
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