Failure to Administer and Document Prescribed Medications
Penalty
Summary
A resident with a medical history including bipolar disorder, schizophrenia, hemiplegia, and traumatic brain injury did not receive prescribed pain and acid reflux medications as ordered. On the night in question, the resident reported not receiving pain medication despite repeated requests to the nurse on duty, who stated the medication was unavailable. The resident experienced significant pain throughout the night until the morning nurse administered the medication. The nurse responsible did not document the administration of the medication or the reason for not providing it in the electronic medical administration record (eMAR). The facility administrator confirmed that the nurse on duty was responsible for administering the medications and that there was no documentation to support that the medications were given or withheld for a documented reason. The Director of Nursing stated that nurses are required to follow physician orders and document any reasons for not administering medications, and that emergency medication storage is available for such situations. Review of the resident's records confirmed that the pain and acid reflux medications were not administered as ordered, and the facility's policy requires medications to be administered and documented according to prescriber orders.