Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to provide services that met professional standards for one resident by not following physician orders for medication administration. The resident, who had diagnoses including atrial fibrillation, anemia, heart failure, hypertension, and respiratory failure, was prescribed Apixaban (an anticoagulant) and cranberry concentrate for UTI prevention. The Medication Administration Record (MAR) and facility documentation revealed discrepancies in the administration of Apixaban, with evidence suggesting the resident may have received double doses on two separate days due to improper handling of short stock medication cards. Staff did not consistently use the calendar date system for dispensing medications, resulting in the potential for duplicate dosing, which could not be definitively confirmed or ruled out by the facility. The resident experienced gross hematuria (blood in the urine) and was subsequently evaluated by a provider, who suspected the bleeding was caused by extra doses of Apixaban. The medication was held as a result, and the bleeding stopped. The resident later developed mouth swelling and pain, prompting a transfer to the emergency department, where no further significant findings were reported except for mouth pain. Interviews with staff confirmed the presence of two medication cards for Apixaban and missing doses from both, as well as a lack of adherence to the prescribed method for dispensing short stock medications. Additionally, the facility failed to provide the correct dosage of cranberry concentrate as ordered by the physician. The resident was given 450 mg instead of the prescribed 500 mg, and this discrepancy was acknowledged by both the administering nurse and the DON. The facility's policy required medications to be administered in accordance with prescriber orders, including verifying the right medication and dosage, but this was not followed in the cases of both Apixaban and cranberry concentrate for this resident.