Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that pharmaceutical services met the needs of residents by not administering medications in accordance with physician orders for two residents. One resident, who was alert and oriented and had diagnoses including bacteremia, diabetes, and hypertension, reported receiving his antibiotic at inconsistent times. Review of his records showed that a scheduled dose of cefazolin was administered late and another dose was not documented as given. The Medication Administration Record (MAR) confirmed these discrepancies, and there was no evidence that the missed or late doses were communicated to the physician as required. Another resident, admitted with diagnoses including pneumonia, congestive heart failure, stroke, and end stage renal disease, had a physician order for vancomycin to be administered on specific days. The MAR indicated that two scheduled doses were not administered, with one dose noted as unavailable. Interviews with nursing staff and the Director of Nursing confirmed that medications were not given on time, not properly documented, and that neither the physician nor the pharmacy were notified when medication was unavailable. Facility policy required medications to be administered as prescribed, within 60 minutes of the scheduled time, and for administration to be recorded immediately, which was not followed in these cases.