Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure the accurate administration of multiple medications as ordered by the physician for one resident with diagnoses including lymphocytic leukemia, neuropathy, pain, and constipation. The resident was cognitively intact and had documented needs for scheduled pain medications and laxatives. Physician orders included gabapentin for neuropathy and Senna-S for constipation, both to be administered at specific times. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that gabapentin was not administered as ordered on one occasion, and Senna-S was missed on four separate occasions within the review period. During interviews and observations, the resident reported pain and ongoing issues with constipation, including self-removal of stool. Staff confirmed that the lack of documentation on the MAR indicated the medications were not given as ordered. The facility's policy required medications to be administered according to prescriber orders, but this was not followed in the identified instances, resulting in significant medication errors for the resident.