Failure to Administer and Document Ordered Medication
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders for one resident, resulting in missed doses of Megestrol Acetate over a two-day period. The resident, a cognitively intact female with a history of nontraumatic intracerebral hemorrhage, hemiplegia, generalized anxiety disorder, muscle weakness, malnutrition, and anorexia, was admitted with an active order for Megestrol Acetate to treat loss of appetite. Review of the Medication Administration Record showed that the medication was not administered as ordered on three consecutive days, and there was no documented rationale for the missed doses in the resident's progress notes. Interviews with nursing staff and facility leadership revealed that medication aides are responsible for administering most medications, and are required to notify a nurse if a resident refuses medication or if a medication is not administered as ordered. Nurses are then expected to follow up with the resident, document the refusal or missed dose in the progress notes, and notify the physician and DON. However, in this case, there was no documentation of the missed doses or any follow-up actions in the resident's records, indicating a failure to follow established procedures for medication administration and documentation.