Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders and established procedures for two residents. In the first case, a female resident with diagnoses including Parkinsonism, Alzheimer's dementia, atherosclerotic heart disease, and atrial flutter was under hospice care and had an active order for Morphine Sulfate 0.5 mL by mouth every 4 hours as needed for pain. On two occasions, nursing staff administered only 0.25 mL of morphine instead of the prescribed 0.5 mL dose, based on a family request, without notifying the physician or hospice prior to the change. Documentation in the controlled substance record and progress notes reflected the lower dose, and interviews confirmed that the nurse did not contact the physician due to being busy, despite knowing it was required. Hospice and pharmacy consultants were not informed of the dose change until after administration, and the facility's own staff acknowledged that any change in medication dosage should be coordinated with hospice and the physician. In the second case, a male resident with a history of lumbar vertebra fracture, dementia, heart disease, and hypertension had an order to monitor pain every shift using a 0-10 scale and to document which pain scale was used. Review of the medication administration record for June showed that, instead of documenting the actual pain level, staff only placed check marks for pain monitoring on most days, with no numerical pain level recorded. Interviews with nursing staff indicated that the resident frequently complained of pain, and the DON confirmed that the pain level should have been documented as per the order. The absence of pain level documentation meant there was no clear record of whether the resident's pain was being effectively managed. Both cases demonstrate failures in following physician orders for medication administration and documentation. The facility's policies require medications to be administered as ordered and pain to be assessed and documented systematically. However, staff did not adhere to these requirements, resulting in incomplete or inaccurate service delivery for the residents involved.