Failure to Administer and Document Physician-Ordered Medication for Allergic Reaction
Penalty
Summary
The facility failed to administer medication as ordered by the physician for one resident. The resident, who was admitted with diagnoses including fibromyalgia and disturbances of skin sensation, experienced facial itching due to a possible allergic reaction. The resident was cognitively intact and required varying levels of assistance with activities of daily living. On the date of the incident, the resident complained of facial itching, and a Change in Condition Evaluation was completed. The primary physician was notified and gave an order to administer Benadryl 25 mg orally every six hours for 14 days as needed for itching. This order was documented in the resident's physician order and care plan, which included the intervention to administer Benadryl as needed for itching. However, review of the Medication Administration Record (MAR) showed that the Benadryl was not signed as given on the date of the incident. The resident later stated in a telephone interview that she did not receive the Benadryl. The LVN involved stated she administered the medication, but there was no documentation to support this. Both the registered nurse supervisor and the director of nursing confirmed during interviews and record reviews that the MAR was not signed and there was no other documentation indicating the medication was given. Facility policy requires that the individual administering medication must document the administration on the MAR, including date, time, dosage, route, symptoms, results, and signature. The lack of documentation and failure to administer or record the administration of Benadryl as ordered constituted the deficiency.