Failure to Follow Physician's Orders for Medication Administration Timing
Penalty
Summary
The facility failed to ensure that medications were administered according to physician's orders for one resident. The resident, who was cognitively intact and had diagnoses including post-traumatic stress disorder, osteoarthritis, and generalized anxiety disorder, had specific physician's orders for a benzodiazepine to be given at bedtime and a compound opioid pain medication to be given every eight hours as needed. The orders explicitly stated that these two medications should not be administered within two hours of each other, a directive that was also documented in the resident's psychiatric clinic notes and confirmed by the prescribing provider. A review of the resident's medication administration history revealed that on four separate occasions, the benzodiazepine and the opioid pain medication were administered within minutes of each other, in direct violation of the two-hour separation requirement. These administrations were documented by various LPNs, who later confirmed during interviews that they had given the medications together, often at the resident's request. The staff acknowledged awareness of the facility's policy to follow physician's orders and the importance of adhering to medication administration guidelines, but still proceeded to administer the medications concurrently. Interviews with facility leadership, including the Medical Director, Assistant Director of Nursing, and Director of Nursing, confirmed their expectation that staff follow physician's orders and facility policy, specifically regarding the separation of benzodiazepine and opioid administration. The facility's medication administration policy also required medications to be given as ordered by the physician. Despite these policies and expectations, the staff failed to comply with the specific order, resulting in the identified deficiency.