Failure to Follow Physician Orders and Proper Resident Identification in Medication Administration
Penalty
Summary
The facility failed to follow physician orders for two residents in relation to medication administration. One resident, admitted with depression and adjustment disorder and experiencing pain from recent surgery and multiple fractures, had a physician order for oxycodone not to exceed 40 mg per day. On one occasion, the resident received 50 mg of oxycodone in a single day, exceeding the prescribed limit. Documentation showed that the medication was signed out and administered by an LPN, and the error was later acknowledged by the Director of Nursing Services. Another resident, admitted with depression, was given the wrong medication after an LPN addressed the resident by the incorrect name and administered the roommate's morning medication, which included 60 mg of duloxetine. The resident did not notice the error at the time and took the medication. The LPN, who was working through a staffing agency and unfamiliar with the residents, realized the mistake only after attempting to give medication to the correct resident. The error was acknowledged by both the LPN and the facility administrator.