Failure to Administer Medications as Ordered and Inadequate Documentation
Penalty
Summary
The facility failed to administer medications according to physician's orders for one resident, resulting in a medication error rate of 20%, which exceeds the acceptable threshold. During a medication pass, an LPN administered several medications to the resident but omitted Carvedilol 25mg, Fluticasone 50mcg nasal spray, and Duloxetine 60mg, all of which were ordered to be given at that time. Additionally, the resident's medication administration record (MAR) showed duplicate and conflicting entries for Fluticasone-Salmeterol (Advair) Inhaler, leading to the potential for over-administration. A physician's note had previously identified that the dosing regimen for this inhaler exceeded the recommended frequency, but there was no documentation of follow-up or correction in the electronic medical record. There was also no documentation in the electronic medical record regarding the missed doses or any notification to the prescribing physician or pharmacy about the omissions. The facility's policy requires that medications be administered as ordered and that any errors or omissions be documented, with appropriate notifications made. The Director of Nursing confirmed that staff should use backup pharmacy stock if available and notify the provider and pharmacy if medications are not in stock, as well as document any missed doses, but these steps were not followed in this instance.