Nurse Altered Medication Order Without Physician Notification
Penalty
Summary
Facility nursing staff failed to ensure that a resident received care and services according to accepted standards of clinical nursing practice. Specifically, a licensed registered nurse altered a medication order label for a resident's Trazodone prescription without documented evidence that the physician was notified or made aware of the change. The original physician's order directed a specific dosage, which was later discontinued and replaced with a new order. However, the medication blister packet on the medication cart was found to have been manually altered by facility staff to reflect a different dosage, with the label changed from 0.5 tablet to 2 tablets at bedtime. There was no documentation in the resident's progress notes indicating that the physician was consulted regarding the available tablet strength or the alteration of the medication order label. The resident involved had multiple diagnoses, including Major Depressive Disorder, Adjustment Disorder, Unspecified Dementia, and Metabolic Encephalopathy, and was assessed as having severely impaired cognitive function and moderate depression. Interviews with facility staff revealed a lack of clarity regarding who was responsible for altering the medication label, and the Assistant Director of Nursing indicated that nurses were allowed to use their own judgment to adjust medication orders for non-narcotic medications. This action was not supported by facility policy or standards of nursing practice, which require that medication orders be administered only as prescribed and that any concerns or discrepancies be communicated to the prescribing physician.