Failure to Administer Medications According to Physician Orders and Facility Policy
Penalty
Summary
A deficiency occurred when the facility failed to administer medications to a resident in accordance with physician orders and the facility's policy and procedure for medication administration. The resident, who had diagnoses including unspecified convulsions, sepsis, and congestive heart failure, was prescribed Depakote in specific dosages and at scheduled times. Review of the Medication Administration Audit Record (MAAR) showed that on two occasions, the resident's Depakote was not administered within the required one-hour window of the scheduled time. Specifically, the 125 mg Depakote tablets scheduled for 5 p.m. were given at 9:42 p.m., and the 250 mg Depakote tablet scheduled for 9 a.m. was administered at 11:24 a.m. During interviews, the resident reported experiencing a seizure while in the facility, attributing it to not receiving anti-seizure medication on time. The Director of Nursing (DON) confirmed the medication administration times did not comply with the facility's policy, which requires medications to be given within one hour of the scheduled time unless otherwise specified. The facility's policy and the DON both acknowledged that failure to administer Depakote on time could result in convulsions.