Medication Administration Deficiency in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered by a physician for two residents, leading to a deficiency in compliance with pharmacy policies and procedures. For one resident, a registered nurse administered 15 ml of a medication, despite the physician's order indicating a dosage of 10 ml daily. This discrepancy was noted during an observation of the medication administration process, and the nurse referred to a physical chart that confirmed the physician's order for a lower dosage. The Director of Nursing later clarified that the order should have been 10 ml daily, and an incident report was completed. Another resident experienced a failure in medication administration when a scheduled medication for high blood pressure was not administered. The resident's son expressed concern about the medication causing low blood pressure, and the nurse contacted the physician to discuss the issue. The physician then ordered a reduced dosage of 2.5 mg daily, which the son agreed to. The resident required substantial assistance for daily activities and had a history of hypertension, which was relevant to the medication management. The facility's policy on medication administration emphasizes that medications should be administered as prescribed and in accordance with good nursing practices. However, the incidents involving these two residents demonstrate a failure to adhere to these standards, resulting in the administration of incorrect dosages and missed medications. These deficiencies were identified through observations, record reviews, and interviews with staff members.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 is no longer at the facility. Resident's #6 order was corrected. The physician was called and was advised of the incorrect dosage being administered, and no new orders were given. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken? All resident's with orders were reviewed, any deficiency found were corrected immediately. An audit was conducted which reviewed a sample of new orders for accurate transcription and if any deficiencies were found, they were addressed immediately. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur? Standard parameters will be established through the therapeutic and pharmacy committee. All nursing staff will be educated on utilizing the standard parameters for orders, unless, the physician ordered otherwise. An audit will be conducted to review orders daily by the nurse managers and pharmacist for 7 days, then weekly for 30 days and then monthly for 3 months. If any deficiency is found, it will be corrected immediately. Nursing staff will be educated on accurately administering medications per physicians orders by following the Five Rights. A sample of new orders will be randomly audited on all units by the unit manager or designee daily for 7 days, then weekly for 30 days, and then monthly for 3 months. Additionally, the pharmacy representative will be conducting random medication administration pass observations weekly for 3 months; if any deficiencies are observed, education will be provided to the nurse immediately. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? This corrective action plan will be monitored through a dedicated PIP and nursing home leadership will report findings to the monthly Quality and Risk Management committee. The committee will also evaluate the need for extended audits and further education, if necessary, after 90 days.