Failure to Administer Medication as Ordered Due to Stock Supply Mismatch
Penalty
Summary
The facility failed to administer medication in accordance with professional standards for one resident during a medication pass. Specifically, a nurse administered a tablet containing Calcium 600 mg with Vitamin D 400 units, instead of the physician-ordered Calcium 600 mg with Vitamin D 200 units, due to the facility's stock supply only containing the higher dose. The nurse did not clarify the order with the provider to match the available stock medication. Review of facility policy confirmed that medications are to be administered as ordered by the physician, ensuring the right dosage. Staff interviews revealed that the facility relied on the consultant pharmacy's stock and that the nurse should have contacted the provider to update the order to reflect the available medication.