Failure to Administer and Document Ordered Medications
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician, specifically an anxiolytic (Diazepam) and an ear drop medication (Debrox Otic Solution). According to the Medication Administration Record (MAR), the resident did not receive the prescribed doses on multiple occasions, and the nurse documented a code indicating 'other, see nursing note.' However, there was no documentation in the nurse's progress notes explaining why the medications were not administered or what actions were taken in response to the missed doses. This lack of documentation was in direct contradiction to the facility's policy, which requires nurses to document the reason for withholding medication and any subsequent steps taken, as well as to notify the physician if a medication is refused or withheld two or more consecutive times. The resident involved had multiple diagnoses, including influenza, diabetes, hypertension, hyperlipidemia, heart block status post pacemaker, chronic kidney disease stage III, spinal stenosis, epilepsy, and muscle weakness. Despite the nurse's acknowledgment during interview that she was responsible for administering the medications and should have documented the reasons for non-administration, she was unable to recall why the medications were not given or why documentation was not completed. The Director of Nursing confirmed that the expectation is for nurses to document the reason for missed medications and notify the physician, which was not done in this case.