Failure to Administer Physician-Ordered Nitroglycerin Patch
Penalty
Summary
A review of records and interviews revealed that a resident with diagnoses including diabetes, heart failure, hypertension, angina pectoris, and end stage renal disease did not receive a physician-ordered 24-hour transdermal nitroglycerin patch for angina pectoris as documented on the medication administration record. The resident was cognitively intact, as indicated by a BIMS score of 15. On the day the medication was missed, the resident complained of chest pain to an RN, who assessed vital signs that were within normal limits. Later that same day, the resident was found unresponsive and without a pulse, and CPR was initiated. The facility's Director of Nursing (DON) and administrator were unable to determine why the nitroglycerin patch was not administered, despite attempts to contact the agency CMA responsible. The CMA provided inconsistent explanations and ultimately, the facility requested that the CMA not return. The failure to administer the medication as ordered constituted a significant medication error for the resident.