Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that physician orders for medication administration were followed or clarified for one resident, identified as Resident 8. This resident, who was admitted with diagnoses including hemiplegia, hemiparesis, and cognitive communication deficit, had a moderate cognitive impairment as indicated by a BIMS score of 9/15. During a medication administration observation, an LPN crushed several medications for the resident, including Aspirin, Plavix, Ferrous Gluconate, Folic Acid, and a Multi-Vitamin, without a documented physician order to do so. The facility's policy required that medications be crushed only when appropriate and safe, with a physician's documentation or clinical reason provided, which was not adhered to in this case. The LPN involved indicated that the medication label would be checked to determine if medications could be crushed and that pharmacy or physician consultation would occur if there were questions. However, the LPN confirmed that there was no physician order to crush the medications, and a new order or clarification should have been obtained. The Consultant Pharmacist and the Director of Nursing both confirmed the necessity of having a physician order to crush medications to ensure resident safety. The facility's policy on administering medications required adherence to prescriber orders, which was not followed in this instance, leading to the deficiency.