Medication Administration Errors and Lack of Physician Orders
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for two residents, resulting in medication administration errors. For one resident with diagnoses including diabetes, chronic pain, and a gastrointestinal stromal tumor, a nurse administered two doses of Oxycodone 15 mg at the same scheduled time without a physician's order for the additional dose. The nurse realized the error only after the resident was about to take the second dose, and the clinical record did not contain documentation of a physician's order for the extra medication given. Facility policy requires that medications be administered only with a valid physician's order and that the correct dose be verified each time. For another resident dependent on renal dialysis with multiple chronic conditions, including end stage renal disease and HIV, the facility failed to administer scheduled morning medications on dialysis days. The resident's medication administration record showed that several medications were not given on multiple mornings when the resident was away for dialysis, and there was no documentation that these medications were administered upon the resident's return. Interviews confirmed that the resident did not receive most of his morning medications after returning from dialysis, except for one medication taken before meals.