Failure to Administer Prescribed Medications as Ordered
Penalty
Summary
A resident with diagnoses including aftercare following joint replacement surgery, cerebral ischemia, and hypertensive heart disease did not receive her prescribed morning medications on a specific date. The medications missed included antihypertensives, an antiplatelet, a supplement, an antidepressant, an antianginal, and an antidiabetic agent. The medication administration record indicated these medications were not administered because the resident was marked as unavailable. The resident later reported feeling dizzy that afternoon and realized she had not received her morning medications. She did not inform facility staff of the missed dose at the time. The facility only became aware of the missed medication administration several days later, on the resident's discharge date, when the issue was brought to their attention. The nurse responsible was a relatively new staff member and had not communicated any difficulties in locating the resident, despite being checked on multiple times by supervisory staff. Documentation showed that the nurse practitioner was informed of the missed dose, but no new orders were received. The facility's process for notifying supervisors, providers, and the resident or responsible party was not followed at the time of the incident.