Failure to Administer Medications per Physician Orders and Guidelines
Penalty
Summary
The facility failed to administer medications according to physician orders and established guidelines for four residents, resulting in significant medication errors. For one resident with a history of bacterial conjunctivitis, the prescribed Maxitrol eye drops were not documented as administered, and a subsequent order for Polytrim eye drops was not resumed after a cancelled ophthalmology appointment, despite ongoing infection. Staff confirmed that transcription errors and lack of follow-up with the provider led to the resident not receiving the required medications as ordered. Another resident, who was prescribed gabapentin three times daily for nerve pain, did not receive the medication at appropriate intervals. The medication was administered at inconsistent times, sometimes with less than the recommended six-hour interval between doses. Staff acknowledged that the medication schedule should have been adjusted to ensure proper spacing, as advised by the facility's pharmacist, but this was not done. Two additional residents with diabetes were prescribed Lispro insulin to be administered before meals. Observations showed that both residents received their insulin injections after they had finished eating, contrary to physician orders. Nursing staff attributed the delay to time constraints, and facility leadership confirmed that medications should be given as ordered. These failures in medication administration were directly observed and confirmed through interviews and record reviews.