Failure to Administer Ordered COPD Medication Due to System Lapse
Penalty
Summary
The facility failed to implement a system to ensure that medications were available and administered as ordered for a resident with significant medical needs. The resident, who was cognitively intact and dependent on staff for dressing and toileting, had diagnoses including asthma, COPD, and diabetes mellitus. A physician order was placed for Anoro Ellipta, a medication used for COPD, but review of the electronic medication administration record (eMAR) showed that the medication remained in 'Pharmacy Pending Confirmation' status and was not administered as prescribed. The medication was present in the facility, but the order had not been confirmed in the system, resulting in the resident not receiving the medication since it was prescribed. Interviews with facility staff revealed a lack of awareness and follow-through regarding the medication order. The registered nurse acknowledged the medication was in the cart but had not been confirmed or given. The DON was unaware that the medication had not been confirmed or administered, and the consultant pharmacist stated that confirmation should have occurred promptly. The facility's policy required timely and accurate transcription of medication orders, but this was not followed, leading to the deficiency.