Failure to Administer Ordered Medication Due to Missed Order Entry and Oversight
Penalty
Summary
A deficiency occurred when the facility failed to obtain and administer a physician-ordered medication, Pyridostigmine Bromide, for a resident diagnosed with myasthenia gravis and other complex conditions. Upon admission, the resident had an active order for Pyridostigmine Bromide 30 mg three times daily, but the medication was not administered for a period spanning several days due to unavailability. The omission was not identified until the resident was admitted to the hospital, and upon return, the medication was reordered. Review of the Medication Administration Record showed that nine doses were missed between 05/30/25 and 06/02/25. Pharmacy documentation indicated the medication was delivered but returned due to the resident's hospital admission, and a subsequent delivery occurred days later. Interviews revealed that the physician was unaware of the medication order until after the resident's hospital stay, and the DON stated that nurses are responsible for entering medication orders upon a resident's return from the hospital, with unit managers conducting chart audits. The DON was not aware of the missed medication and believed the order was overlooked. Facility policy requires medications to be administered as ordered and discrepancies to be reported to the nurse manager, but this process was not followed in this instance.