Failure to Address Pharmacist's Recommendation for Aspirin Dosage Clarification
Penalty
Summary
The facility failed to address discrepancies identified by the consultant pharmacist regarding a resident's aspirin order. The resident, who had diagnoses including dementia, cerebral stroke syndrome, and cerebrovascular disease, was admitted with severe cognitive impairment and a history of stroke. The resident's Medication Administration Records over several months included an order for aspirin every other day, but the strength of the medication was not specified. The consultant pharmacist noted the missing dosage in multiple monthly reviews, but there was no documentation that the facility addressed or clarified the recommendation. Interviews revealed that a nurse administered 81 mg aspirin every other day from the facility's stock, believing it was the correct order, despite the absence of a specific physician's order for aspirin. The DON, who had recently assumed her role, discovered that several pharmacy recommendations, including the missing dosage clarification, had not been completed by previous nursing leadership. The DON was unaware of the missing dosage until it was brought to her attention by surveyors.