Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
Staff 17, a former agency LPN, failed to administer prescribed medications and treatments according to physician orders for seven sampled residents. The missed medications included Omeprazole Suspension and water flushes for a resident with esophageal reflux and cerebral palsy, Pantoprazole Sodium for a resident with chronic gastritis and GERD, and Levothyroxine for several residents with hypothyroidism. Additionally, Carbidopa-Levodopa for Parkinson's Disease and Oxycodone for pain were not administered as ordered. These omissions were documented in the Medication Administration Records (MARs) for the affected residents on the specified date. The Director of Nursing Services (DNS) confirmed that Staff 17 did not administer the prescribed medications and treatments during her scheduled shift. The DNS stated that all physician orders are expected to be followed and that medications should be administered as ordered. The facility attempted to contact Staff 17 through the agency staffing company, but was unable to reach her, as two phone numbers were disconnected and the third went to a generic voicemail with no return call received. The residents involved had significant medical histories, including conditions such as esophageal reflux, cerebral palsy, chronic gastritis, hypothyroidism, Parkinson's Disease, and pain management needs. The failure to administer medications and treatments as ordered was confirmed through record review and staff interview, with the DNS acknowledging the lapses in medication administration for all seven residents on the specified date.