Failure to Follow Physician's Orders and Medication Administration Policy
Penalty
Summary
The facility failed to follow physician's orders and administer medications according to professional standards and facility policy for one resident. Facility policy required that medications be administered by licensed nurses as ordered by the physician, with proper documentation on the Medication Administration Record (MAR) and Controlled Drug Receipt Record/Disposition Form. For a resident with diagnoses including Parkinson's Disease, Sepsis, COPD, Metabolic Encephalopathy, Depression, and Anxiety, the physician's order for Clonazepam was changed to 0.25 mg via PEG tube twice daily. However, the Controlled Drug Receipt Record/Disposition Forms showed that two doses of 0.25 mg (totaling 0.5 mg) were signed out as given at bedtime on multiple dates, rather than the single 0.25 mg dose ordered by the physician. Review of the MAR confirmed that the resident received Clonazepam 0.25 mg via PEG tube twice daily, but the narcotic log indicated that double the ordered dose was documented as administered at bedtime on several occasions. The Regional Director of Clinical Services confirmed that only one 0.25 mg dose should have been given at bedtime per the most recent physician's order, and that the documentation did not match the current order. This discrepancy demonstrates a failure to ensure medications were administered and documented in accordance with physician orders and facility policy.