Failure to Ensure Medication Availability and Administration per Physician Orders
Penalty
Summary
The facility failed to ensure that medications were available and administered in accordance with physician orders for three residents. One resident with chronic pain syndrome, opioid dependence, osteomyelitis, and bacteremia was ordered to receive IV Cefazolin every eight hours. On two occasions, the resident did not receive the scheduled 2 PM dose because they were out of the facility at the hospital for another medication. The LPN responsible did not notify the nursing supervisor, physician, or APRN about the missed doses, and the supervisor was unaware of the omission. The APRN and DON both stated they would have expected to be notified of the missed antibiotic doses. Another resident with a history of substance use disorder was ordered to receive Methadone 115 mg daily. The medication was not available in the facility for four consecutive days, and the resident missed multiple doses. The resident was subsequently transferred to the hospital for Methadone administration after experiencing withdrawal. Facility staff interviews revealed that the Methadone nurse, responsible for obtaining the medication from the clinic, was not aware of the unavailability, and the RN supervisor was not notified of the missed doses until after several had been omitted. The APRN was also not notified of the missed doses until after the resident was transferred to the hospital. A third resident, also with opioid abuse, was ordered Methadone 75 mg daily. The medication was not available for administration on one occasion, and the reason for the unavailability could not be identified. The RN supervisor was not aware of the missed dose, and the DNS could not explain why the medication was not available. Facility policy directed that Methadone should be retrieved and administered as ordered, but this was not followed in these cases.