Failure to Administer Admission Medications per Physician Orders and Policy
Penalty
Summary
A deficiency occurred when a resident admitted for rehabilitation, with multiple complex diagnoses including Zoster Meningitis, heart failure, chronic pulmonary disease, cerebral infarction, chronic pulmonary edema, and acute kidney failure, did not receive scheduled morning medications as ordered by the physician on the day following admission. The facility's policy allows for the use of an automated dispensing machine to provide first doses and emergency medications, with staff authorized and trained to access the machine when medications from the pharmacy are not yet available. However, the resident's medications, which included several critical prescriptions, were not administered in the morning as required because staff waited for the pharmacy delivery rather than utilizing the dispensing machine. Interviews with facility staff revealed a misunderstanding or misapplication of the policy regarding the use of the automated dispensing machine. The registered nurse on duty stated that they were instructed to wait for pharmacy deliveries and only use the machine for emergent medications. The Assistant Director of Nursing confirmed that the resident did not receive the morning medications and acknowledged this was unacceptable. The Director of Nursing also stated that the nurse should have used the dispensing machine to provide the medications. The medications were ultimately delivered by the pharmacy later in the day, but the delay resulted in the resident missing scheduled doses.