Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders for two residents. For one resident with diagnoses including diabetes mellitus, low back pain, and COPD, the physician order specified that oxycodone 30 mg should be administered by mouth every six hours as needed for severe pain levels of seven to ten. However, the Medication Administration Record (MAR) showed that licensed nurses administered oxycodone when the resident's pain level was six on multiple occasions. The Director of Nursing (DON) confirmed that the nurses did not follow the physician's order and should have performed a proper pain assessment and contacted the physician for any necessary adjustments. For another resident with metabolic encephalopathy, secondary hypertension, and dementia, the physician order required diltiazem 60 mg to be given every six hours for high blood pressure, with instructions to hold the medication if the systolic blood pressure (SBP) was below 110. The MAR indicated that diltiazem was administered when the resident's SBP was 108/70. The DON acknowledged that the medication should have been held according to the physician's order to prevent further decrease in blood pressure. A review of the facility's policy and procedure for medication administration emphasized the importance of following the five rights of medication administration and adhering to physician orders, including taking vital signs immediately before administering medications when required. The DON confirmed that the facility's policy was to follow the physician's order, and the failures identified were not in accordance with this policy.