Failure to Clarify Unclear Medication Order Prior to Administration
Penalty
Summary
Licensed Nurse 2 (LN 2) failed to clarify a physician's order for calcium carbonate before administering the medication to a resident. During a medication pass, LN 2 prepared and gave one tablet of 500 mg calcium carbonate, despite the physician's order indicating 'calcium carbonate 1250 (500 Ca) mg, give one tablet by mouth two times a day.' LN 2 acknowledged that the order was unclear and should have been clarified with the physician prior to administration to ensure the correct dosage was given. The Director of Nursing (DON) confirmed that nursing staff are expected to clarify unclear orders with the physician and that nurses should contact the doctor whenever in doubt. The facility's medication administration policy also requires staff to consult the attending physician or medical director if a dosage is believed to be inappropriate or excessive. The failure to clarify the order resulted in the resident receiving a potentially incorrect dosage of medication.