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F0658
D

Medication Administered Without Physician's Order

Greensburg, Pennsylvania Survey Completed on 06-18-2025

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

A registered nurse administered Epinephrine to a resident without a physician's order. The resident, who was cognitively intact and required staff assistance for daily care, had a diagnosis of respiratory failure and was receiving Amoxicillin Potassium Clavulanate per physician's order. After receiving the antibiotic, the resident complained of shortness of breath, and the nurse, suspecting a reaction to the new medication, gave 1 gram of Epinephrine in the resident's right thigh. A review of the clinical record showed no documented evidence of a physician's order for the administration of Epinephrine. The facility's policy required that all medications be administered in accordance with prescriber's orders, and the Pennsylvania Nurse Practice Act mandates that registered nurses carry out nursing care actions within professional standards, including obtaining necessary orders for medications.

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