Failure to Follow Medication Administration Standards and Orders
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards for four residents, resulting in multiple medication management deficiencies. For one resident with a G-tube, a LPN administered ondansetron by mouth despite the physician's order specifying administration via G-tube, and the order itself contained conflicting instructions for route of administration. The LPN did not clarify the order with the provider before administering the medication, contrary to facility expectations. Another resident self-administered a steroid inhaler (Arnuity Ellipta) without staff oversight, kept the inhaler at bedside without a locked box, and did not rinse their mouth after use as required by manufacturer instructions. The resident's medication administration record did not include an order for the inhaler, and staff confirmed that the resident should have had an order and should have been instructed to rinse their mouth after use. A third resident received a steroid inhaler (fluticasone-salmeterol) from a LPN, who did not assist or remind the resident to rinse their mouth after administration, and the physician's order lacked this instruction despite manufacturer guidelines. For a fourth resident with diabetes, a LPN administered insulin using a pen device without priming the pen beforehand, which is necessary to ensure proper dosing. Staff interviews confirmed that insulin pens should be primed before each use and that residents using steroid inhalers should be assisted to rinse their mouths after administration. These actions and omissions were inconsistent with facility policy, pharmacy guidelines, and professional standards of practice.