Failure to Provide Pharmaceutical Services and Administer Medications per Physician Orders
Penalty
Summary
The facility failed to provide pharmaceutical services and routine medications as ordered for two residents. For one resident with a history of hemiplegia, hemiparesis, cerebral infarction, dementia, dysphagia, schizophrenia, and a gastrostomy, the physician ordered isosorbide mononitrate 30 mg oral tablet to be administered via g-tube once daily. However, the pharmacy supplied only the extended-release (ER) form of the medication, which is not intended to be crushed or administered via g-tube unless specifically prescribed. Nursing staff did not notice the discrepancy between the physician's order and the medication label, and proceeded to crush and administer the ER tablets via g-tube on multiple occasions. Both the pharmacy and nursing staff failed to clarify the order or communicate the unavailability of the immediate-release form, resulting in the resident receiving the medication in a manner not consistent with the physician's order. Another resident, with diagnoses including diabetes mellitus, gastrointestinal hemorrhage, and schizoaffective disorder, was ordered metformin 1000 mg to be given once daily with food or a meal. During medication administration, a nurse attempted to give the metformin without ensuring the resident had food, contrary to the physician's order. The nurse acknowledged that the medication should have been administered with food and that failing to do so did not align with the order. The facility's policy and procedure for medication administration required licensed nurses to administer medications per the physician's order, perform three checks (comparing the physician's order, pharmacy label, and medication administration record), and resolve any discrepancies before administration. In both cases, these procedures were not followed, resulting in medications being administered in a manner inconsistent with physician orders.