Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration and documentation of medications for two residents. For one resident with chronic obstructive pulmonary disease, dysphagia, and multiple contractures, the physician ordered tramadol HCl in two dosages for pain management. However, a Licensed Vocational Nurse (LVN) did not sign the controlled drug inventory sheet immediately after administering the medication, as required by facility policy. The Director of Nursing confirmed that this omission could cause discrepancies during narcotic counts and that the LVN was expected to document administration at the time of delivery. For another resident with acute respiratory failure, pneumonia, and severe cognitive impairment, the physician ordered Zyvox, an antibiotic, to be administered twice daily for seven days. The Medication Administration Record and progress notes showed that three doses of Zyvox were missed because the medication was not available and had not been delivered by the pharmacy. The nursing staff did not check the emergency kit for the medication or notify the physician about the missed doses to obtain further orders or extend the course of antibiotics. Facility policies required medications to be administered as prescribed and for controlled substances to be documented on the inventory sheet at the time of administration. The Director of Nursing acknowledged that the failure to notify the physician about the missed antibiotic doses and the lack of immediate documentation for controlled substances constituted a failure to follow these policies.