Failure to Administer Medication According to Physician Order and Documentation Requirements
Penalty
Summary
A deficiency occurred when a resident with diagnoses including spastic quadriplegic cerebral palsy, dysphagia, and scoliosis did not receive medication as ordered. The resident had a physician's order for diazepam 2.5 mg to be administered four times daily. According to the June Medication Administration Record (MAR), four doses of diazepam were documented as given on a specific date. However, the corresponding narcotic count sheet indicated that the medication was not removed for the morning and noon doses on that date. Interviews with facility staff confirmed that the medication was signed off as administered on the MAR but was not signed out on the controlled medication log, as required by facility policy. Review of the records suggested that the medication may not have actually been administered to the resident, despite documentation to the contrary. Facility policy requires that controlled substances be signed out on the narcotic sheet after administration, which was not done in this instance.