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F0755
D

Incorrect Form of Aspirin Administered Due to Failure to Follow Physician's Order

Palm Desert, California Survey Completed on 06-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A licensed vocational nurse (LVN) administered an enteric coated (EC) aspirin 81 mg tablet to a resident instead of the prescribed chewable aspirin 81 mg tablet. The physician's order and the Medication Administration Record (MAR) specified that the resident, who was recovering from a hip replacement, was to receive a chewable aspirin 81 mg tablet by mouth twice daily. During a medication pass observation, the LVN was seen preparing and administering the EC aspirin tablet, which was not in accordance with the physician's order. Upon review, both the LVN and the Director of Nursing (DON) confirmed that the wrong form of aspirin was given, acknowledging the difference between EC and chewable aspirin in terms of absorption and onset of action. The facility's policy required verification of medication orders and comparison with the MAR and medication label prior to administration, as well as triple-checking the medication before giving it to the resident. These procedures were not followed, resulting in the administration of the incorrect medication form.

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