Failure to Administer Ordered Medications and Unordered Medication Dispensed
Penalty
Summary
A deficiency occurred when a resident did not receive two doses of their ordered medications, carvedilol and tramadol, as documented in the Medication Administration Record (MAR) for a specific morning. The nurse's note indicated that these medications were not administered due to awaiting pharmacy delivery, despite the facility having both medications available in contingency stock. The carvedilol available was of a lower dose, but two tablets could have been given to achieve the prescribed dosage, and the physician was not contacted for clarification. Additionally, the facility's Automated Medication Dispensing System (AMDS) records showed that Eliquis, a medication not prescribed for the resident, was dispensed to them by an LPN, who later did not recall this action. The resident had multiple diagnoses, including a right fibula fracture, cardiomyopathy, heart failure, and kidney failure. The facility's policies require medications to be administered according to physician orders and that only prescribed medications be removed from the AMDS. The surveyor found that the resident's prescribed aspirin had a major interaction with Eliquis, and three other medications had moderate interactions, according to a drug interaction checker. The facility's leadership acknowledged that the physician should have been contacted regarding the medication issue, but this was not done.