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F0658
D

Failure to Clarify Incomplete Medication Order Before Administration

Shippenville, Pennsylvania Survey Completed on 05-01-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow nursing standards of practice by not ensuring that a physician was contacted regarding an incomplete medication order prior to administering medication to a resident. Specifically, a resident with diagnoses including osteomyelitis, weakness, and type II diabetes was admitted and had a physician's order for Piperacillin Sodium-Tazobactam Sodium Intravenous Solution. The order did not specify the amount for reconstitution or the rate of administration. Despite this incomplete order, the RN administered the medication for the first and second doses without clarifying these critical details with the physician. Documentation in the resident's clinical record showed that the medication was administered at specific times, and it was later noted that it was given at the wrong rate and route. Facility documents confirmed that the RN did not contact the physician to clarify the incomplete order before administering the medication. The Nursing Home Administrator acknowledged that this failure did not adhere to professional nursing standards, as required by both state regulations and the facility's own job descriptions for RNs.

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