Failure to Administer Medications as Ordered Resulting in Significant Medication Error
Penalty
Summary
A deficiency occurred when a resident with a history of orthopedic aftercare, left above the knee amputation, and joint surgery aftercare was not administered medications as ordered. The resident was cognitively intact and required supervision with activities of daily living. Physician orders specified that the resident should receive oxycodone 10 mg by mouth six times per day and oxycodone 5 mg by mouth every six hours as needed (PRN). On a specific date, the Medication Administration Record (MAR) documented that the resident received routine oxycodone as ordered, but there was no documentation supporting administration of the PRN oxycodone 5 mg. Further review of the Controlled Drug Record revealed that the resident actually received two tablets of oxycodone 10 mg and two tablets of oxycodone 5 mg at three different times that day, which did not match the physician's orders or the MAR documentation. The Director of Nursing confirmed that the records indicated the resident received incorrect doses of both oxycodone 10 mg and 5 mg, and that the MAR did not accurately reflect the administration of these medications. Facility policy required medications to be administered accurately and in accordance with physician orders, and for staff to record the dose, route, and time of administration on the MAR.