Failure to Administer Ordered Medication as Prescribed
Penalty
Summary
The facility failed to follow physician's orders for a resident with multiple complex medical conditions, including lobar pneumonia, heart failure, COPD, diabetes type 2, and chronic pulmonary edema. After returning from a hospital stay for respiratory failure and pneumonia, the resident experienced significant weight gain and edema, prompting the physician to order bumetanide, a diuretic, with specific dosages and administration times. Despite these orders, the medication administration record showed several missed doses of bumetanide due to reasons such as waiting for delivery, drug unavailability, and the need for order clarification. In some instances, only partial doses were given, and at other times, the medication was placed on hold. The nursing progress notes documented ongoing symptoms, including persistent edema, shortness of breath, and a decline in the resident's physical condition. The Director of Nursing confirmed that the medication should have been obtained from the contracted or back-up pharmacy and administered as ordered. The resident was eventually placed on comfort care and subsequently died. The deficiency centers on the facility's failure to provide treatment and care according to physician orders, as evidenced by the missed and incomplete administration of prescribed medication.