Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident, who was admitted with a medical diagnosis that included subcortical and flaccid conditions affecting the right dominant side. The resident was prescribed Pregabalin 75 mg to be administered three times a day, starting from the day of admission. However, the resident did not receive the medication during five administration opportunities, as documented in the medical records. The deficiency arose because the prescription for Pregabalin was not sent to the pharmacy, and the medication was not available in the emergency drug kit. Despite the nurses' attempts to contact the pharmacy, they did not have the prescription, and there was no documentation indicating that the physician was notified to provide the necessary prescription. The facility's emergency medication drug list showed that Pregabalin 25 mg was available, but the required 75 mg dosage was not administered. Interviews with the nursing staff and the Director of Nursing revealed that the facility's process for handling new admissions and controlled medications was not followed. The nurses were expected to notify the physician and document the need for a prescription, but this was not done. The Director of Nursing confirmed that the medication should have been administered as prescribed, and the nurses should have continued to contact the physician until the medication was delivered.
Plan Of Correction
Immediate actions taken for residents found to have been affected: Resident #1 was discharged from the facility on. Identification of other residents having the potential to be affected: Current residents in the facility were reviewed by to ensure their medications requiring hard scripts were available in the medication cart. No other residents were affected by the deficient practice. Actions taken/systems put into place to reduce risk of future occurrence: Staff Development Coordinator/designee will re-educate licensed nurses by to ensure physicians are notified when a hard script is needed for a new medication and will continue to follow up with physician and/or pharmacy until medication is received. How the corrective actions will be monitored to ensure the practice will not recur: DON/designee will review new admissions to ensure hard scripts were received or sent to pharmacy to ensure medication is delivered and available to the resident 3 times a week for 2 weeks then 2 times a week for 2 weeks then weekly. The administrator will oversee audit completion and report findings in the monthly Risk Management/QA Committee meeting for 3 months or until substantial compliance is achieved.