Failure to Administer Prescribed Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident's prescribed medication was administered as ordered. According to the medical record, a physician had ordered Xopenex Inhalation Nebulization Solution to be given via ventilator four times daily. On one occasion, the medication was not administered at the scheduled time, and there was no documentation that the physician was notified of the missed dose. The facility's policies require medications to be administered as prescribed and for the prescriber to be contacted if there is a delay or unavailability of medication. Interviews with the resident, respiratory therapist, and Director of Nursing confirmed that the medication was not given as scheduled due to the assigned respiratory therapist leaving early and no coverage being provided. The resident reported being left without respiratory therapy for hours and expressed fear due to not receiving the breathing treatment on time. The DON acknowledged that the RN Supervisor should have administered the medication in the absence of the respiratory therapist.