Failure to Administer Medications per Physician Orders and Standards of Practice
Penalty
Summary
Staff failed to accurately administer medications according to physician orders and professional standards of practice for two residents. For one resident with anemia, diabetes, and arthritis, a registered nurse set the infusion rate of micafungin at 200 ml/hr instead of the ordered 100 ml/hr over one hour. This discrepancy was confirmed by both the Director of Nursing and the nurse involved, who acknowledged the medication should have been infused at the correct rate as per the physician's order. For another resident with chronic obstructive pulmonary disease, seizures, congestive heart failure, and anxiety, carvedilol was administered multiple times when the resident's pulse was below the ordered parameter of 60 beats per minute. The medication administration record showed several instances over three months where the medication was given despite the resident's pulse being outside the specified range. The Director of Nursing confirmed that medications should not be administered if vital signs are outside the ordered parameters and that the provider should be notified in such cases.