Failure to Administer Medications as Prescribed
Penalty
Summary
A deficiency occurred when a registered nurse failed to administer medications as prescribed to a resident with multiple diagnoses, including schizoaffective disorder, COPD, major depressive disorder, and syndrome of inappropriate secretion of anti-diuretic hormone. During a medication pass, the nurse prepared and presented a medication cup to the resident, who noticed that her Bumex (diuretic) and Aspirin (salicylate) were missing. The nurse then returned to the medication cart to retrieve and administer the missing medications after being prompted by the resident. Further review of the resident's physician orders revealed that Fluphenazine was to be given as two 10 mg tablets twice daily, but only one tablet was prepared and administered. Additionally, the nurse provided an 81 mg enteric-coated Aspirin instead of the prescribed chewable tablet. The nurse acknowledged these errors during an interview, confirming that the medications were not prepared or administered as ordered until the resident pointed out the omissions.