Failure to Administer Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for one resident. The resident, who had a complex medical history including chronic respiratory failure with hypoxia, asthma, tracheostomy status, and spastic quadriplegic cerebral palsy, was observed to have missed multiple scheduled doses of critical medications. Specifically, the resident did not receive the prescribed evening dose of Bactrim DS, an antibiotic ordered for pneumonia, as well as scheduled doses of Olanzapine and Klonopin. The medication administration records and incident reports indicated that although these medications were available in the facility's back-up supply, the nurse did not retrieve them for administration. Progress notes reflected that the pharmacy had been called, but there was no documentation of provider notification or consideration of changes to the medication orders to address the missed doses. The Director of Nursing confirmed that the medications in question were present in the back-up supply and acknowledged that the nurse should have administered them from this supply. The resident's medical record lacked documentation regarding any discussion with the provider about extending or adjusting the medication orders due to the missed doses. The failure to administer these medications as ordered was identified through observation, record review, and staff interview, and was corroborated by facility documentation and the resident's medication administration records.