Failure to Administer Prescribed Medication Before Care
Penalty
Summary
The facility failed to provide adequate and appropriate healthcare for a resident, as evidenced by the failure to administer prescribed medication prior to a care treatment. The resident had an order to be medicated 30 to 60 minutes before care treatment to ensure comfort, but this order was not followed. During an observation of the resident's care, the resident expressed discomfort and pain, indicating that the medication was not administered as required. The care nurse responsible for the resident's treatment did not stop to assess the resident's pain level or offer additional medication when the resident showed signs of discomfort. The nurse stated that they would call the doctor if there were any changes in the resident's condition and explained that they usually medicate residents 30 to 60 minutes before care. However, the Electronic Medication Administration Record (EMAR) showed no documentation of the medication being administered as ordered prior to the care treatment. The resident confirmed that they usually receive medication before care, which helps with their discomfort, but they were unsure if they were medicated on the day of the observation. The facility's policy on care procedures emphasizes the importance of verifying physician orders and documenting how the resident tolerated the procedure, but these steps were not adequately followed in this instance.
Plan Of Correction
FS Right to Adequate and Appropriate Health Care 400.022(1)(1) Plan for specific resident: On an in-service was provided to the medicine nurse to give medication per doctor's orders and to sign medication administration record after. To communicate to the treatment nurse after medication is given. On an in-service was given to staff (care nurse) on verifying with medication nurse if medication was administered. On verifying with the resident if medication was taken to ensure that medication was received before care treatment. On stopping care if resident complains of discomfort, access the level of notifying the doctor for adjustment of medication to manage resident's level. On an order from the doctor to increase the order of 325mg to 2 tabs given orally 30-60 min prior to care. Method to assure compliance for other residents: On in-service was provided to the nurses by the DON on following doctor's orders when administering medications and to sign medication administration record as given. On communicating between medication nurse and treatment nurses to ensure residents for care were medicated. On assessing resident's comfort or level during care. If the resident complains of discomfort or level, care process must stop. Access level and notify physician for modification of management. System: On care nurse conducted an audit of the residents receiving care with orders of medication before change to ensure that orders are present that adequately manage their level during care. Monitoring: As of the quality assurance and performance improvement coordinator will use a monitoring tool to check on a weekly basis, for a period of 3 months, residents with medications prior to care treatment that they receive their medication as ordered and the medication ordered is adequate to manage resident's. This will be done to ensure 100% compliance.