Failure to Timely Administer Newly Ordered Medication
Penalty
Summary
The facility failed to ensure that a newly ordered medication, furosemide 20 mg, was received and administered in a timely manner as ordered by the physician for a resident with congestive heart failure and severe cognitive impairment. The resident was noted to have swelling, redness, and blistering on the left lower extremity, prompting a physician's order for furosemide to be given twice daily for four days. However, the medication was not documented as administered on the evening of the order date, nor the following morning and evening, with the first documented dose given two days after the order was placed. There was no documentation that the facility pharmacy had been contacted regarding the delay in delivery, nor evidence that the medication was accessed from the Emergency Drug Kit, despite its availability. The DON confirmed the pharmacy's delivery schedule and was unable to explain the delay in receiving the medication. The packing slip indicated the medication was delivered two days after the order, and facility records did not show any interim measures taken to provide the medication as ordered.