Medication Administered Without Valid Physician Order
Penalty
Summary
A deficiency occurred when a resident with dementia, diabetes, and congestive heart failure was administered a Zofran tablet for nausea without a valid physician's order. The resident, who was severely cognitively impaired, requested something for nausea. A Kentucky Medication Aide (KMA) checked the electronic health record and found no order for Zofran, then informed an LPN, who incorrectly stated that Zofran was available as a standing order. However, review of the facility's standing orders confirmed that Zofran was not included. Despite this, the KMA administered Zofran to the resident after the LPN entered an order under the Medical Director's name, but without prior authorization or notification to the Medical Director. Interviews revealed that the Medical Director was not contacted about the new medication and was unaware of the order, expressing that she would have needed more information before approving Zofran for the resident. The LPN later acknowledged the mistake, stating she should have obtained a proper order before administration. The Director of Nursing and the Administrator both confirmed that staff are expected to know the standing orders and obtain physician orders for all medications not on the list, emphasizing the importance of following these protocols for resident safety. The facility was unable to generate a Pyxis report to verify the medication dispensing process.