Failure to Administer and Document Physician-Ordered Medications and Treatments
Penalty
Summary
Staff failed to implement physician's orders for two residents. For one resident with dementia and anxiety, clinical records showed that morphine sulfate and haloperidol were not administered as ordered on multiple occasions, with no documentation of administration or resident refusal. Specifically, morphine was not given at 9:00 a.m. or 1:00 p.m. on one date, and haloperidol was not given at 9:00 a.m. on the same date and at 6:00 a.m. on another date. There was no evidence in the clinical record that the resident had refused these medications. For another resident with peripheral vascular disease, chronic kidney disease, and congestive heart failure, staff did not document the application of a prescribed wound care treatment on two separate dates. The physician's order required daily cleansing and dressing of a right wrist wound, but there was no evidence in the clinical record that the treatment was provided or refused by the resident. The DON confirmed that staff should have documented administration or refusal of medications and treatments, and that there was no such documentation for the identified dates.