Failure to Administer and Document Ordered Medication
Penalty
Summary
The facility failed to follow professional standards of clinical practice and its own policy regarding medication administration for a resident with significant respiratory conditions, including acute and chronic respiratory failure, COPD, and hypertension. The resident, who was cognitively intact, had a physician order for Morphine Sulfate oral solution to be administered four times daily for air hunger. Review of the electronic Medication Administration Record (eMAR) and the controlled substance administration record revealed that the 4:00 A.M. dose was not administered as ordered, and there was no documentation of administration or resident refusal for that dose. Interviews with facility staff confirmed that medications should be administered and documented according to physician orders and facility policy, with no blank spaces left on the eMAR. The Director of Nursing verified that the blank space on the eMAR indicated the medication was not given as ordered. The facility's policy requires that all medications be signed for after administration, and the failure to do so for this resident's Morphine dose constituted a breach of both professional standards and facility policy.