Failure to Follow Physician Orders and Ensure Medication Administration
Penalty
Summary
The facility failed to follow physician orders and ensure proper medication administration for two residents. For one resident, surveyors observed a straw in the resident's water pitcher on multiple occasions, despite a physician's order prohibiting straw use due to a high risk of aspiration. Both nursing staff and the DON confirmed the resident should not have a straw, and the Speech-Language Pathologist explained that straw use increased the risk of choking for this resident, who had previously been NPO and was upgraded to thin liquids. Despite these orders and explanations, the straw was not promptly removed and was found again during a night observation. Another resident reported to surveyors that he often ran out of medication and did not receive it until it arrived from the pharmacy, specifically mentioning medication for restless leg syndrome. Review of the medication administration record revealed missed doses of Gabapentin, Ropinirole, and Synthroid, with some doses not documented as administered. An RN confirmed the missed doses and verified that the medications were available in the pyxis system at the time, indicating they could have been administered but were not.