Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
Staff failed to administer medications as ordered by physicians for two residents, as observed through record reviews, staff and resident interviews, and policy review. Facility policy requires medications to be administered and documented according to physician orders, with any missed or withheld doses to be explained and documented. In the first case, a resident with multiple diagnoses, including COPD, prostate cancer, and herpes zoster, had physician orders for both oral and topical Acyclovir to treat shingles. The first oral dose was not administered due to unavailability, and three additional doses were not signed as administered on the MAR. The resident filed a complaint, and comparison of his personal records with the MAR confirmed these discrepancies. Facility staff could not confirm whether the medication was given or simply not documented, and acknowledged that all doses must be documented, with reasons provided for any missed doses. In the second case, another resident was admitted for post-amputation care and required IV antibiotics (Ceftazidime) every eight hours via a PICC line. The hospital discharge summary specified the timing for the next dose, but the first dose was not administered until approximately 28 hours after admission, resulting in a significant gap in treatment. The MAR confirmed the delay, and staff interviews revealed that emergency medication storage was available, and procedures were in place to obtain or substitute medications if unavailable. However, these procedures were not followed, and the required documentation and physician notification were not completed. Both cases demonstrate a failure to follow physician orders and facility policy regarding medication administration and documentation. Staff interviews confirmed the expectation for complete and accurate documentation, including reasons for any missed doses, but this was not consistently practiced. The deficiencies were identified through direct observation, record review, and interviews with residents and staff.