Failure to Administer Prescribed Medication for Chest Pain
Penalty
Summary
A deficiency was identified when a resident with a medical history of chest pain secondary to unstable angina did not receive medication as ordered by the attending provider. The provider's order specified that Nitroglycerin Tablet Sublingual 0.4 MG should be administered sublingually every 5 minutes as needed for chest pain, up to three doses. Record review and staff interviews revealed that when the resident complained of chest pain during the night, staff administered an antiemetic (Zofran) instead of the prescribed Nitroglycerin. Documentation did not show that the Nitroglycerin was given, and both the RN and the Director of Nursing confirmed that the resident should have received the angina medication according to the provider's order.