Failure to Administer Muscle Spasm Medication as Ordered
Penalty
Summary
A resident with diagnoses including neuropathy, malignant melanoma, hypothyroidism, and muscle weakness was admitted with intact cognitive function and the capacity to make decisions. The resident had a physician's order for Baclofen 5 mg three times daily for muscle spasms, which was discontinued, and a new order for Cyclobenzaprine HCl 10 mg every 8 hours as needed for muscle spasms was issued. On the day following the medication change, the resident reported experiencing muscle spasms and discomfort, stating he had not received his muscle spasm medication since the previous night. The LVN present was unaware of the new Cyclobenzaprine order and did not review the complete order summary, resulting in the resident not receiving the prescribed medication when requested. The medication administration record confirmed that Cyclobenzaprine was not administered until several hours after the resident's complaint. The DON acknowledged that the facility failed to administer medications and treatments as ordered by the physician, attributing the delay to the LVN's failure to review the updated orders. Facility policy required medications to be administered as prescribed and in accordance with written orders, which was not followed in this instance.