Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to administer prescribed medications as ordered for two residents. One resident with a diagnosis of hematuria did not receive the scheduled 9AM dose of Midodrine 5mg, a medication used to increase blood pressure, because the medication was not available in the pyxis or cycle med roll. The nurse identified the missing medication, contacted the pharmacy, and notified the physician, but the medication was not administered until 10:59AM, nearly two hours after the scheduled time. The resident's blood pressure was documented as low prior to the scheduled dose, and the delay was confirmed through nursing notes and the medication administration record. Another resident with macular degeneration did not receive the scheduled 9AM dose of prednisolone acetate ophthalmic suspension 1% eye drops, which are ordered four times daily to relieve eye pressure. The nurse did not administer the medication because the resident was in the dining room, and facility policy did not allow medication administration in that setting. The nurse subsequently decided to skip the 9AM dose and planned to administer the next scheduled dose early. The medication administration record confirmed the 9AM dose was not given, and the resident reported feeling increased pressure in the eyes due to the missed dose.