Failure to Administer and Document Physician-Ordered Medications
Penalty
Summary
A deficiency occurred when a resident did not receive physician-ordered medications, including Enoxaparin Sodium and Diazepam, over several days. The Medication Administration Record (MAR) showed multiple omissions for both medications, with no documented nursing notes explaining the reasons for non-administration. There was also no evidence that the physician was notified about the missed doses or that any rationale for withholding the medications was recorded. The facility's policy required timely and accurate medication administration and documentation, which was not followed in this instance. The resident involved had a medical history including trauma subdural hematoma, alcohol abuse, and major depressive disorder. The resident required varying levels of assistance with activities of daily living and was noted to have changes in mental status, including being unresponsive and having dilated pupils, prior to being transferred to the hospital. The MAR and nursing progress notes did not contain explanations for the missed doses of Enoxaparin Sodium or Diazepam, nor was there documentation of medication refusals or physician notification as required by facility protocol. Interviews with facility staff, including the Nurse Practitioner and Director of Nursing, confirmed that there was no documentation to explain the medication omissions. The staff interviewed were unable to recall the specific circumstances surrounding the missed doses, and attempts to contact the nurses responsible at the time were unsuccessful. The lack of documentation and communication regarding the missed medications constituted a significant medication error as identified by the surveyors.