Failure to Administer PRN Medication per Physician Order
Penalty
Summary
A deficiency occurred when the facility failed to administer a prescribed as needed (PRN) medication, Torsemide, according to physician orders for a resident with a history of congestive heart failure, atrial fibrillation, coronary artery disease, hypertension, renal failure, and localized edema. The resident had an order for daily weights and to receive PRN Torsemide if their weight exceeded 116.0 pounds. Over a seven-day period, the resident's weight was consistently above this threshold, but there was no documentation of the PRN medication being administered as ordered. Review of the electronic health record (EHR) and medication administration record (MAR) confirmed the absence of PRN Torsemide administration on the days when the resident's weight exceeded the specified limit. Observations during this period noted the resident had 2+ pitting edema in the lower extremities and later required oxygen for low saturations, eventually being hospitalized for pneumonia and fluid overload. Interviews with nursing staff revealed a lack of awareness of the PRN order, with some staff stating there were no parameters related to daily weights and others discovering the PRN order only upon review. The PRN order was not visible in the usual workflow of the electronic MAR, requiring staff to access a separate tab to view it. The facility's medication administration policy required correct and timely administration of medications and documentation of PRN medication efficacy. However, the process for entering and displaying PRN orders in the electronic system led to the order being overlooked, resulting in the resident not receiving the prescribed PRN Torsemide despite clear indications based on daily weight measurements.