Failure to Follow Physician Orders and Accurately Document Medication Administration
Penalty
Summary
Licensed nursing staff failed to follow physician orders regarding medication administration for multiple residents. For one resident with end stage renal disease on dialysis, blood pressure medications were administered on scheduled dialysis days despite an order to hold medications on those days. The nurse misinterpreted the order, believing it only applied when the resident was out of the facility, and did not clarify the order with the nurse practitioner. Both the nurse practitioner and the Director of Nursing confirmed that the order should have been clarified and that blood pressure medications should have been held prior to dialysis. Another resident with a fungal infection did not receive a newly prescribed dose of fluconazole in a timely manner. The assigned nurse failed to obtain the medication from the emergency kit when it was not delivered by the pharmacy, resulting in a two-day delay in treatment. Additionally, the antibiotic medication count sheet for this resident was inaccurate, as the nurse documented preparation of the medication but did not actually administer it, leaving all doses intact in the medication supply. For two other residents receiving pregabalin, the medication count sheets were not accurately maintained. In both cases, the number of doses documented on the count sheets did not match the actual number of doses remaining in the medication bubble packs. The nurses involved admitted to forgetting to document the preparation or administration of the medication, which resulted in discrepancies in the controlled medication records. The Director of Nursing acknowledged that such inaccuracies could lead to medication errors or undetected controlled medication discrepancies.