Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician's orders regarding the administration of narcotic and psychotropic medications for four residents. In multiple instances, medications were administered at incorrect intervals or after the orders had been discontinued. For example, one resident with chronic pain and moderate cognitive impairment received Hydrocodone-Acetaminophen every 6 hours instead of the ordered every 8 hours, resulting in two medication errors. Documentation confirmed that the medication was not administered according to the prescribed schedule, although no side effects were noted during the review period. Another resident with a history of dementia and a femur fracture received Hydrocodone after the order had expired, with the medication being administered five times without a valid physician's order. The resident was also receiving other pain management medications, and records indicated that the resident was monitored for pain and did not appear to be in distress during this period. The nurse responsible for these errors was suspended and later terminated following the investigation. Additional deficiencies were identified for two other residents. One resident with dementia and a history of anxiety received Ativan at intervals shorter than prescribed, with doses given five hours apart instead of twice daily as ordered. Another resident with severe cognitive impairment received Trazodone at 2:00 AM instead of at bedtime as ordered. In all cases, the medication administration records and interviews confirmed that the nurses did not follow the physician's orders, resulting in medication errors. The medical director and administrator both acknowledged these errors and confirmed that the facility's expectation is for licensed nurses to adhere strictly to physician orders when administering medications.