Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to administer medications in accordance with the physician's orders for a resident, leading to a deficiency in following professional standards of practice. Specifically, a Licensed Practical Nurse (LPN) was observed preparing to administer medications to a resident and noted a discrepancy in the dosage of Vitamin D3. The Medication Administration Record (MAR) indicated that the resident was to receive 1000 International Units (IU) of D3 daily, as per the physician's orders. However, the medications available and administered were 2000 IU, which was not in accordance with the prescribed dosage. Further investigation revealed that the incorrect dosage of D3 had been administered on multiple occasions. Another LPN confirmed administering the 2000 IU dosage without altering the medication, and the Director of Nursing acknowledged awareness of the incorrect dosage being given. The facility's failure to adhere to the physician's orders for medication administration resulted in a deficiency, as the nurses did not follow the prescribed dosage for the resident.
Plan Of Correction
1. Physician order was clarified and updated to reflect 2000 units, consistent with the original dosage on. The dosage was administered on MARs audited facility-wide for compliance with physician orders initiated and completed. 2. Medication administration training initiated for licensed nurses; projected completion date. 3. Random audits twice weekly for 30 days led by DON or designee; pharmacy consultant monthly reviews, change in pharmacy services provider beginning. Reviewed in QAPI. 4. Report to QA committee will continue monthly for recommendations and or revisions. Completion Date: