Failure to Clarify Aspirin Dosage in Medication Order
Penalty
Summary
The facility failed to ensure that medication orders for a resident met professional standards of quality, specifically by not clarifying the dosage of aspirin to be administered. A resident with a history of dementia, cerebral stroke syndrome, and cerebrovascular disease was admitted with an order for aspirin to be given every other day, but the dosage was not specified in the Medication Administration Record (MAR) from January to July 2025. Despite this omission, nursing staff administered 81 mg of aspirin every other day from the facility's over-the-counter stock, based on the nurse's assumption and belief in a standing order, which was not present in the resident's physician orders. Interviews revealed that the nurse responsible for administering the medication was unaware of the missing dosage in the original order and relied on her understanding of typical practice for residents with a history of stroke. The Director of Nursing confirmed that there were two available dosages of aspirin in stock (81 mg and 325 mg) and acknowledged that the order should have been clarified to specify the correct strength. The issue was only identified after surveyor intervention, and the resident's physician was not available for interview during the survey.