Failure to Administer Medication According to Physician's Orders
Penalty
Summary
A deficiency occurred when a nurse failed to administer medication in accordance with the physician's orders for a resident with a history of fractures, anemia, and bipolar disorder. The resident had a current order for Cephalexin 500mg to be given four times daily for cellulitis, but the nurse initially prepared Cefadroxil 500mg, a discontinued antibiotic, for administration. This error was identified during a medication pass observation, where the nurse was seen removing the incorrect medication from the resident's bubble pack and placing it into the medication cup. Upon inquiry, the nurse reviewed the orders again, realized the mistake, and replaced the Cefadroxil with the correct Cephalexin capsule. The nurse stated she was not usually assigned to that unit and expected discontinued medications to be removed from the cart. The facility's policy requires that medications be administered as ordered by the physician and in accordance with professional standards, including verifying the correct medication against the medication administration record (MAR) and ensuring discontinued medications are not available for administration. The Director of Nursing confirmed that the expectation is for nurses to follow the six rights of medication administration and for discontinued medications to be removed from the medication cart. The failure to remove the discontinued Cefadroxil from the cart and the nurse's initial selection of the wrong medication led to the deficiency.