Failure to Clarify Medication Orders for Dialysis Patient
Penalty
Summary
The facility failed to clarify physician's orders for a resident who was cognitively impaired, diagnosed with kidney failure, and received dialysis. The resident had a care plan indicating scheduled dialysis sessions at 6:00 a.m. on specific days, while physician's orders required administration of multiple medications at 9:00 a.m. on those same days. Review of the Medication Administration Records showed that the resident was marked as having received the 9:00 a.m. medications on dialysis days, despite being off-site at dialysis during that time. Further review of nursing notes revealed that the third shift LPN administered the resident's 9:00 a.m. medications before the resident left for dialysis at 6:00 a.m., rather than at the prescribed time. There was no documentation that the physician was notified or that the medication administration times were clarified for dialysis days. The DON confirmed that the orders should have been clarified with the physician.