Failure to Administer and Clarify Physician-Ordered Medications as Prescribed
Penalty
Summary
The facility failed to ensure that physician orders for medication administration were followed and/or clarified in accordance with professional standards of practice for three residents. For one resident, the physician order specified administration of Calcium 600+D3 (Calcium Carbonate-Cholecalciferol) 600-10 mg-mcg once daily, but staff administered Citracal + D (Calcium citrate-Vitamin D3) 315 mg-250 IU instead. This was observed during medication administration, and both the nurse and the unit manager confirmed that the medication given did not match the physician's order in terms of both formulation and dosage. For two other residents, physician orders required administration of Calcium Carbonate-Vitamin D Oral Tablet 600-5 mg-mcg, but staff administered Caltrate + D (Calcium Carbonate-Vitamin D3) 600 mg-400 IU, which did not match the prescribed dosage of Vitamin D. Both the LPN and the unit manager acknowledged that the medications administered differed from the physician's orders and that clarification with the physician and pharmacist should have occurred prior to administration. The facility's in-house pharmacy dispensed the medications that did not match the physician orders, and the consultant pharmacist confirmed that the orders should have been clarified with the physician before dispensing. The Director of Nursing also stated that staff were expected to clarify medication orders with the physician and that the pharmacist was expected to dispense medications as prescribed.