Failure to Administer Medication as Ordered and Incomplete Documentation
Penalty
Summary
The facility failed to administer a prescribed medication, alprazolam 0.5 mg, to a resident as ordered by the physician. Review of the resident's electronic medical record and narcotic administration record showed that the medication was not given on two specific days within a 16-day period, and there was no documented evidence that the medication was administered daily as required. The Director of Nursing confirmed that the facility could not provide documentation to show that the medication was given according to the physician's orders. The resident involved had multiple diagnoses, including cerebrovascular vasospasm, diabetes mellitus, hypertension, malignant melanoma, anxiety disorder, morbid obesity, and major depressive disorder. The resident was cognitively intact, as indicated by a BIMS score of 14. Despite clear physician orders for nightly administration of alprazolam to treat anxiety, the facility's records indicated missed doses and incomplete documentation, resulting in a failure to meet professional standards of quality in medication administration.