Medication Administered Without Physician Order and Improper Supervision
Penalty
Summary
A deficiency occurred when a resident was administered Benadryl 25 mg orally without a physician's order. The resident, who had diagnoses including generalized muscle weakness, hypertension, and dementia but was assessed as having intact cognition, requested Benadryl for itching. The medication was provided by an LVN, who did not verify the presence of a physician's order prior to administration. The LVN admitted to not checking the Medication Administration Record (MAR) or confirming the order before giving the medication, stating it was a mistake and acknowledging the importance of verifying orders to prevent medication errors. Additionally, the Benadryl tablet was left unattended on the resident's bedside table, rather than being administered directly and observed by the nurse. The Registered Nurse Supervisor confirmed that there was no physician order for the Benadryl and that facility policy requires medications to be administered only as prescribed and in accordance with orders. The facility's failure to obtain a physician order and to ensure proper administration and observation of the medication constituted a significant medication error.