Failure to Obtain Orders and Administer Medications as Prescribed
Penalty
Summary
The facility failed to obtain necessary orders and administer prescribed medications as required for a resident who was admitted with multiple diagnoses, including a pressure ulcer with infection. After the resident returned from the hospital, there was a delay in receiving discharge paperwork and medication orders, as neither the family nor the hospital initially provided the necessary documentation. Despite the family informing staff that the hospital would fax the paperwork and later providing pill bottles, the facility did not promptly secure the required orders or administer the antibiotics as prescribed. As a result, the resident did not receive the first scheduled doses of Bactrim DS and Cephalexin at the prescribed times. The medication administration record confirmed that the initial doses were missed, and the antibiotics were not started until later than ordered. Staff interviews revealed that it was not standard procedure to call the hospital for paperwork, and the Director of Nursing acknowledged that the first dose should not have been missed, especially since the medications were available in the facility. The facility's policy requires medications to be administered according to physician orders, which was not followed in this instance.