Failure to Report Medication Regimen Irregularities for NPO Residents
Penalty
Summary
The facility failed to ensure that the pharmacist reported medication regimen irregularities to the attending physician, medical director, and director of nursing, and that these reports were acted upon, as required by facility policy. Specifically, for three residents with NPO (nothing by mouth) orders, the pharmacist did not identify or report discrepancies where oral medications were ordered and documented as administered, despite the NPO status. The facility's policy required monthly drug regimen reviews, including review of the medical chart and reporting of any irregularities, but these steps were not followed for the affected residents. For the residents in question, orders and medication administration records showed that oral medications were prescribed and recorded as given during periods when the residents were under NPO orders. In interviews, the pharmacist stated that discrepancies would be reported if found, but no such discrepancies were indicated in the medication regimen reviews for these residents. The DON reported that medications were given via tube and that nursing staff were aware of the NPO status, but the documentation and pharmacist review did not reflect or address the route discrepancies. This failure was identified through record review and staff interviews, affecting three residents out of a facility census of 116.