Missed Medication Dose Due to Improper Order Readjustment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that medication orders were properly readjusted after being updated, resulting in a resident missing one dose of five prescribed medications. The resident, who had a history of stroke, insomnia, and bipolar disorder, was cognitively intact and able to communicate his needs. He expressed dissatisfaction with receiving medications late at night, prompting the unit manager to communicate his concerns to the physician. The physician approved changing the administration time of the resident's evening medications to an earlier hour, and the orders were updated accordingly. However, during the process of discontinuing the old medication orders and entering new ones, the Director of Nursing did not adjust the start date for the new orders, causing a gap in medication administration. As a result, the resident did not receive his scheduled doses of atorvastatin, depakote, ezetimibe, melatonin, and trazodone on the evening following the order change. Staff interviews confirmed that the medications did not appear on the electronic medication administration record for that evening, and the resident did not receive them. The resident did not report any adverse effects and remained alert and oriented.