Failure to Administer Ordered Medications Resulting in Resident Pain and GI Symptoms
Penalty
Summary
The facility failed to provide routine medications as ordered for a resident with multiple medical diagnoses, including type 2 diabetes, chronic kidney disease, hypertension, major depressive disorder, and chronic ulcer. The resident had physician orders for Tramadol for pain and Creon for indigestion, but the medication administration records showed that both medications were marked as not available on several occasions. Despite documentation that Creon was delivered to the facility, nursing staff did not administer it because it could not be located in the medication cart. Additionally, Tramadol was not provided because the prescription was not properly signed and thus not filled by the pharmacy. As a result of not receiving the prescribed medications, the resident experienced pain, vomiting, and diarrhea. The resident reported not receiving the pancreatic enzyme or pain medication and stated that the lack of Creon led to gastrointestinal symptoms and inability to get out of bed. The resident also reported keeping medication in his drawer and self-administering due to inconsistent administration by nursing staff. Interviews with facility staff confirmed the medication was not given as ordered, and that the failure to provide Creon could have contributed to the resident's symptoms.