Failure to Administer Medications as Prescribed
Penalty
Summary
A deficiency occurred when a nurse failed to administer medications to a patient as prescribed by the physician. The patient, who had diagnoses including dysphagia, asthma, chronic respiratory failure with hypoxia, COPD, and lack of coordination, required specific administration instructions for several medications. During a medication pass, the nurse prepared and provided the medications to the patient but did not ensure that the medications were taken according to the physician's orders. Specifically, the patient did not take Metoprolol with food, did not take Potassium Chloride with the prescribed four to six ounces of water, and did not rinse her mouth after using the Pulmicort inhaler. The nurse also did not provide instructions or directions for the use of these medications and left the room before confirming that the patient had followed the required steps. The patient's care plan included interventions for swallowing problems, asthma/COPD, and nutritional risk, all of which required staff to monitor and assist with medication administration and hydration. Despite these documented needs, the nurse allowed the patient to self-administer medications without a physician's order for self-administration and without providing the necessary assistance or supervision. The nurse also failed to notify the physician when medications were not administered as prescribed, such as when Metoprolol was given more than two hours after the scheduled time and without food. Facility policy required medications to be administered as prescribed, within the appropriate time frame, and with adherence to any special instructions, such as taking medications with food or fluids and rinsing the mouth after inhaler use. The policy also specified that self-administration of medications must be authorized by the physician and documented in the care plan. In this case, the nurse did not follow these policies, resulting in the patient not receiving medications in accordance with physician orders.
Plan Of Correction
C 0900 - Nursing Service - Administration of Medication A) IMMEDIATE CORRECTIVE ACTION: 1. On 10/7/2025 the RN supervisor immediately assessed patient 9 for any signs of adverse outcome regarding medications that were not administered per MD orders. Vital signs were taken and recorded as follows: BP=139/76, P=68, R=16, O2 Sat=96% and Pain level=0/10. Patient 9 was deemed stable with no issues and remained verbally responsive, alert and oriented x 4 with no apparent complaint at this time. MD and responsible party were notified. RN supervisor provided patient 9 with education on proper method of taking her medication. Patient verbalized understanding. 2. On 10/7/2025 DON initiated and completed a one-on-one in-service with LVN 4 respectively to discuss the policy and procedure (P/P) on medication administration. The emphasis was on accurately following MD orders for specific medications as per MD order and/or pharmaceutical recommendation (i.e. with food with sufficient fluids, rinsing mouth between medications, etc.) DON also discussed the potential of unwanted effects from medications being administered incorrection. DON reiterated the importance of "pour, pass, and sign" medication administration procedure. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025 upon identification of deficient practice, DON, ADON, and RN Supervisor immediately completed a facility round to observe all other charge nurses during medication pass to ensure residents' medications are being administered as ordered. No additional residents were affected by the deficient practice. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: On 10/28/2025 DON completed an in-service for all nursing staff on "Medication Administration" P/P, how to handle patients with medication refusals, importance of "pour, pass, sign," and MD/RP notification prior to administration of any additional doses. The discussion was followed by question-and-answer evaluation. On 10/30/2025 facility implemented a medication pass audit that will be completed weekly at random selection by the DON, ADON and/or designee to monitor Charge Nurses' medication administration performance on proper and accurate medication administration. Any noted deviations will be corrected immediately and continued mentoring and performance improvement plans will be implemented as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report weekly audit findings to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025 C0900