Failure to Provide Individualized Physician Oversight During Medication Administration
Penalty
Summary
Facility staff failed to provide physician services for three residents by not ensuring individualized physician oversight and response to a nurse's inquiry regarding medication administration. On a specific date, only one nurse was present on a unit with 54 residents, instead of the scheduled two nurses. The nurse on duty reported being unable to administer medications as scheduled due to the overwhelming workload and the absence of a second nurse. The nurse attempted to seek guidance from a nurse practitioner, who stated she could not provide orders for all residents and advised the nurse to use her own judgment and critical thinking. No individualized physician direction was documented for the affected residents. For the residents involved, clinical records showed that multiple medications, including those for allergies, spinal stenosis, nasal congestion, rhabdomyolysis, muscle spasms, high blood pressure, increased eye pressure, pain, and constipation, were administered late or not at all. Medication administration audit reports confirmed that scheduled doses were significantly delayed, and in some cases, medications ordered to be given three times a day were omitted because the late administration would have resulted in doses being too close together. The nurse on duty made decisions about which medications to administer based on her own judgment without specific physician input for each resident. Interviews with staff, including the nurse, nurse practitioner, pharmacist, and administrator, confirmed the lack of individualized physician response and documentation regarding the medication administration issues. The facility's policy required the attending physician to participate in assessment, care planning, and to provide consultation or treatment when called by the facility. However, this process was not followed, resulting in a failure to ensure that residents were under appropriate physician care during the incident.