Failure to Administer Medications According to Physician Orders
Penalty
Summary
Staff failed to administer medications in accordance with physician orders for three residents. For one resident with COPD and diabetes, the Medication Administration Record indicated multiple medications were to be given at 9:00 a.m. and insulin glargine at 8:00 a.m.; however, the resident reported not receiving her morning medications by 10:50 a.m., and record review confirmed medications had not been administered as of 12:30 p.m. Another resident with end stage renal disease and diabetes was scheduled to receive several medications at 9:00 a.m., but observation showed the Director of Nursing did not administer these until 11:48 a.m. A third resident with atrial fibrillation and hypertension was to receive medications at 9:00 a.m. and midodrine with meals, but observation revealed medications were not given until 11:36 a.m., and a nurse's note indicated midodrine was not administered with breakfast as ordered. In an interview, the Administrator confirmed that the late administration of medications was due to staffing issues. The deficiencies were identified through clinical record reviews, resident and staff interviews, and direct observation, and were cited under 28 Pa. Code 211.12(d)(1)(5) Nursing services.