Failure to Administer Medications as Ordered by Physician
Penalty
Summary
A deficiency was identified when a resident did not receive medications as ordered by the physician. Document review and staff interviews revealed that multiple medications, including hydroxyzine HCL, doxycycline monohydrate, Entresto, and trimethoprim, were not administered at the prescribed times. For example, hydroxyzine was given more than two hours late for one dose and less than two hours apart for another, contrary to the physician's orders. Other medications, such as doxycycline and Entresto, were also administered several hours later than scheduled, with some doses given late at night instead of in the morning as ordered. Staff interviews confirmed that these administration times did not meet professional standards, with the Assistant Director of Nursing acknowledging that medications given more than one hour before or after the scheduled time constituted a medication error. The Director of Nursing also confirmed that the medications listed were not administered as ordered. These findings were based on a review of medication administration records and staff interpretations, and were substantiated by a complaint from a county agency regarding the resident not receiving medications on time.