Failure to Administer Critical Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by multiple missed doses of critical medications. Upon readmission, the resident had diagnoses including diabetes mellitus, mood disorder, and sepsis. Physician orders were in place for amoxicillin-clavulanate for sepsis, divalproex ER for mood disorder, and Lantus insulin for diabetes. Record review showed that the amoxicillin-clavulanate was not administered as ordered on one occasion, with documentation indicating it was still on order despite being available in the facility’s automated medication dispensing system. The divalproex ER was not administered on two consecutive days, and the Lantus insulin was not given as ordered on one day, with no evidence provided to confirm administration. Staff interviews revealed that the LPN assigned to the resident could not recall administering the Lantus insulin and acknowledged the missed doses of both amoxicillin-clavulanate and divalproex ER. The nurse practitioner was unaware of the missed doses and expected the medications to have been administered as ordered. The President of Operations also confirmed expectations that the medications should have been given and could not provide an explanation for the missed doses. These findings demonstrate a failure to follow physician orders and facility policy regarding timely and accurate medication administration.