Failure to Follow Physician Orders and Accurate Medication Administration Documentation
Penalty
Summary
The facility failed to follow physician orders and ensure proper medication administration for two residents. For one resident with severe cognitive impairment and a recent diagnosis of pneumonia, there was a physician's order for a sodium chloride inhalation nebulization solution to be administered in the morning. On the specified date, the Medication Administration Record (MAR) was signed by a registered nurse indicating the treatment was given, but both the Director of Nursing (DON) and the resident's daughter confirmed that the treatment was not administered. The nurse admitted to not providing the treatment and acknowledged signing the MAR in error, with the medication still in her possession at the time. The resident's daughter discovered the omission later in the day and reported it to staff. For another resident with lymphedema and no cognitive impairment, there was a physician's order for a daily mid-morning dose of Lasix. The MAR indicated the medication was administered, but the resident reported not receiving it, and observation of the medication bubble pack confirmed the dose was still present. The certified medication aide and the DON both acknowledged the missed dose, and the nurse responsible stated that it was not uncommon for medications to be missed without explanation. The nurse also admitted to not notifying anyone about the missed dose and was unclear about the process for handling such situations. Policy review revealed that medication administration must be documented immediately after it is given, and not before, with proper signatures. In both cases, staff documented administration of medications that were not actually given, and there was a lack of communication and follow-up regarding the missed doses. These actions and inactions resulted in the facility failing to meet professional standards of quality in medication administration for the residents involved.