Failure to Follow Physician's Order for PRN Medication Administration
Penalty
Summary
A deficiency occurred when a licensed nurse administered two tablets of Tylenol (acetaminophen) 325 mg to a resident for a temperature of 99 degrees Fahrenheit. The physician's order specified that acetaminophen was to be given via gastrostomy tube (GT) every six hours as needed for fever, but only if the resident's temperature exceeded 100.5 degrees Fahrenheit. The medication administration record (MAR) confirmed that the medication was given outside the parameters of the physician's order. Interviews with the involved LVN and the facility's QA Nurse verified that the medication was administered contrary to the physician's instructions. The QA Nurse acknowledged that the nurse failed to follow the order, and the Director of Nursing (DON) was informed and acknowledged the findings. The resident in question had been readmitted to the facility and subsequently expired, but the report focuses on the medication administration event and the failure to adhere to the prescribed order.