Failure to Administer and Document PRN Medication for Fever
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including urinary tract infection, congestive heart failure, and chronic respiratory failure with hypoxia, did not receive treatment and care in accordance with physician orders and professional standards. The resident, who had severely impaired cognition as indicated by a BIMS score of 3 out of 15, had a physician's order for acetaminophen 650 mg to be administered orally every 4 hours as needed for a temperature of 100°F or above, with a maximum daily dose of 3 grams. On a specific shift, the resident's temperature was recorded at 100.2°F, but there was no documentation that acetaminophen was administered, nor were there any nursing administration signatures on the MAR for that shift and the following one. Additionally, there were no nursing notes, follow-up temperature checks, assessments, or monitoring documented in the medical record after the fever was noted. Interviews with nursing staff and the DON confirmed that the expected protocol would be to administer acetaminophen, monitor the resident, document all actions, and notify the physician and family as appropriate. Facility policies also required documentation of all services provided, including medication administration and any changes in the resident's condition. These actions and inactions led to the identified deficiency.