Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to ensure that medications and treatments were administered in accordance with provider orders for one resident. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for this resident revealed multiple instances where prescribed medications and treatments were omitted or not administered as ordered. These included missed doses of Quetiapine Fumarate, Rosuvastatin Calcium, Vitamin C, Fluticasone Propionate, Spiriva Respimat, Metoprolol Succinate, Potassium Chloride, as well as missed daily weights, catheter care, hydromorphone for pain, and scheduled bladder scans. The facility's policy requires medications to be administered according to prescriber orders and documented immediately after administration, but this was not followed in these cases. The resident involved had diagnoses including acute kidney failure, chronic obstructive pulmonary disease, and acute pancreatitis, and was assessed as cognitively intact. The omissions were identified through review of the resident's records for April and May, which showed specific dates and times when medications and treatments were not given as ordered. During an interview, the DON confirmed that the expectation is for nurses to administer medications and treatments according to provider orders.