Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with diagnoses including GERD, type 2 diabetes mellitus, and bipolar disorder did not receive medications as ordered by the physician. The resident's care plan identified risks for constipation and the use of psychotropic medications, with interventions including medication administration as ordered and monitoring of bowel movements and orthostatic blood pressure. On review of the Medication Administration Record (MAR), it was observed that doses of Pantoprazole Sodium, Linaclotide, and a scheduled blood sugar check were missed. There was no documentation in the nurse's notes to indicate that the resident refused the medications or to provide a rationale for why the MAR was not signed or the medications were not given. Physician's orders specified the administration of Pantoprazole Sodium and Linaclotide once daily and blood sugar checks twice daily. Facility policy requires that all medications be administered safely and timely per physician's orders, with refusals documented in the Electronic Medical Record and progress notes. An interview with the Director of Nursing Services confirmed that all MARs and Treatment Administration Records should be signed and that the nursing team is responsible for ensuring this. The failure to administer medications as ordered and to document refusals or reasons for omission led to the identified deficiency.