Failure to Follow Physician Orders and Medication Release Protocols
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for two residents. For one resident with diagnoses including heart failure, dementia, psychosis, and diabetes mellitus, the facility did not follow the physician's order to administer cephalexin for five days. The medication was not available in the medication cart, resulting in three missed doses, and staff did not notify the physician or pharmacy to obtain the antibiotic from the emergency kit. The resident's medication administration record was left blank for the missed doses, and interviews with facility staff confirmed that the physician's order was not followed. Additionally, the same resident received Humulin R insulin on three occasions despite blood sugar readings below the threshold specified in the physician's order, which directed the medication to be held for blood sugar less than 120 mg/dl. Staff interviews and record reviews confirmed that the insulin was administered contrary to the order, and the facility's policy required nurses to know and follow all aspects of medication administration, including holding medications based on vital signs or test results. For another resident with multiple diagnoses and moderately impaired cognitive skills, the facility allowed a family member to take possession of all the resident's medications, including controlled substances, without a physician's order. The family member refused to sign the narcotic sheet, and staff provided all medications without proper documentation or authorization. Interviews with staff and review of facility policy confirmed that medications should only be released upon discharge with a physician's order, and controlled substances require additional authorization. The facility did not have a policy for therapeutic leave, and the incident was not properly documented in the resident's medical record.