Failure to Administer Ordered Aspirin for CVA Prophylaxis
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to administer aspirin (ASA) 81 mg as ordered by the physician for a resident with diagnoses including dementia and atherosclerotic heart disease. The resident was admitted with a physician's order for daily ASA for cerebrovascular accident (CVA) prophylaxis, and the medication was scheduled to be given at 9 AM. During medication administration, the LVN prepared and administered seven other medications but omitted ASA. The resident noticed the omission and questioned the LVN, who incorrectly stated that ASA was not part of the regimen. The LVN later acknowledged overlooking the physician's order in the Medication Administration Record (MAR) and did not double-check when the resident raised the concern. Further review revealed that the licensed nurses did not check the physician's order and were unaware that the resident was supposed to receive ASA. The facility's policy required medications to be administered safely, timely, and as prescribed, within one hour of the scheduled time. The failure to administer ASA as ordered resulted in the resident not receiving the medication as prescribed, as confirmed by observation, interview, and record review.