Failure to Administer Medication as Ordered Due to Communication and Documentation Errors
Penalty
Summary
The facility failed to follow physician's orders for one resident by not administering a prescribed medication, Invega Sustenna, in a timely manner. The resident, who had diagnoses including dementia, schizoaffective disorder, anxiety, depression, and persistent mood disorder, had a physician's order for an intramuscular injection of Invega Sustenna to be given on a specific date each month. On the scheduled date, the medication order was entered into the medical record in such a way that it appeared on the Certified Medication Technician (CMT) Medication Administration Record (MAR), even though a CMT is not authorized to administer this injection. The CMT documented that the medication was not given but did not notify the charge nurse, as required by facility policy. The charge nurse on duty was not informed that the medication had not been administered, and there was no documentation in the resident's progress notes indicating that the missed dose was reported or addressed. The Director of Nursing was unaware of the missed administration until contacted by the resident's family. The failure to communicate and follow up on the missed medication resulted in the resident not receiving the prescribed injection as ordered by the physician.