Failure to Ensure Proper Administration of Physician-Ordered Medication
Penalty
Summary
The facility failed to ensure that physician-prescribed medications were administered as ordered for a resident with multiple diagnoses, including cellulitis, chronic kidney disease, edema, and paranoid schizophrenia. The resident had a physician's order for Bumetanide (Bumex) 2 mg tablet to be taken by mouth each morning for fluid retention, with the medication scheduled for administration at 6 AM daily. Documentation showed the medication was signed as given at the scheduled time. However, direct observation revealed that the resident kept the medication at his bedside, split the tablet in half, and self-administered it in two separate doses, contrary to the prescribed order. Interviews with staff confirmed that nurses are required to verify medication orders, bring medications directly to the resident, and remain with the resident until the medication is swallowed. The Director of Nurses stated that the resident should not be splitting the dose and that the medication should be taken as ordered. The facility's Medication Pass policy requires staff to sign the MAR after administering medication but did not provide additional policies regarding proper medication administration. The failure to ensure the medication was administered as ordered resulted in a deficiency.