Failure to Follow Medication Administration Orders and Standards
Penalty
Summary
The facility failed to ensure medications were administered according to physician's orders and professional standards of practice for two residents. For one resident with COPD and dementia, a physician's order required the use of an inhaled medication (fluticasone-salmeterol) with instructions to rinse the mouth after each use. During medication administration, the LPN provided the inhaler but did not instruct or offer the resident to rinse his mouth afterward, as required by the order and professional guidelines. The DON confirmed that the medication brands were equivalent and that mouth rinsing should have been performed. For another resident with a history of traumatic brain injury and quadriplegia, a physician's order specified administration of three tablets of Vitamin B-12 daily. The LPN was observed preparing and administering only one tablet instead of the ordered three. Upon review of the order, the LPN acknowledged the error and stated that the correct dosage should have been given. These actions demonstrate a failure to follow physician orders and established medication administration protocols.