Failure to Administer Medications per Physician Orders and Manufacturer Guidelines
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and manufacturer guidelines for two residents, resulting in a medication error rate of 26.9%. In one instance, an LPN administered Voltaren External Gel to a resident without using the required dispensing film to measure the prescribed two grams, instead providing a 'pea-sized' amount at the resident's request. The LPN was unsure how this amount compared to the ordered dose and did not contact the provider for clarification or an alternate order, despite the medication administration record and label specifying the required dosage. For another resident, a TMA prepared and administered multiple medications by crushing them and mixing with applesauce, including medications such as Aspirin, Colace, Furosemide, Metoprolol, Acetaminophen, and Vitamin D3. The Gabapentin capsule was opened and mixed with applesauce, and Potassium Chloride ER was mixed with water. The TMA stated that orders to crush medications typically came from therapy and would be communicated during shift reports or displayed in the electronic medical record (EMR) banner. However, a review of the EMR and order summary revealed no provider order authorizing the crushing of medications for this resident. Interviews with the ADON, DON, and consulting pharmacist confirmed that a provider order is required before medications can be crushed and administered in this manner. The facility's own policies also require physician authorization and documentation for crushing medications. Despite this, medications were administered crushed without the necessary provider order, and the required documentation was not present in the EMR or on the medication administration record.