Failure to Administer Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including Parkinson's Disease, Diabetes, Morbid Obesity, Atrial Fibrillation, Epilepsy, Congestive Heart Failure, Chronic Kidney Disease Stage 3, tracheostomy, gastrostomy, and ventilator dependence, did not receive Clonazepam 2 mg as ordered via PEG tube for three scheduled doses. Medical record review showed that the medication was not administered on three occasions despite being prescribed twice daily. The registered nurse responsible confirmed that the medication was not in the medication cart, did not retrieve it from the emergency drug cart, and did not contact the pharmacy to obtain it. The DON later confirmed that the medication was available in the emergency drug cart and should have been administered as ordered.