Failure to Administer Medications as Ordered by Physician
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident. Specifically, a medication aide (MA-Q) administered a multivitamin with minerals to a resident instead of the ordered multivitamin, as documented in the resident's medication administration record. The resident, an elderly female with multiple diagnoses including osteoporosis, diabetes, hypertension, and dementia, had a physician's order for a multivitamin without minerals. Observations confirmed that the incorrect medication was prepared and administered, and the medication aide later confirmed giving the multivitamin with minerals rather than the prescribed multivitamin. Interviews with staff, including another medication aide, an LVN, and the DON, revealed awareness of the importance of administering the correct medication and the differences between a multivitamin and a multivitamin with minerals. The facility's policy required verification of medication orders and checking medication labels against the electronic medication administration record, but these procedures were not followed in this instance, resulting in the administration of the wrong medication to the resident.