Failure to Notify Physician and Clarify Orders Before Holding Scheduled Medication
Penalty
Summary
A deficiency occurred when a licensed nurse failed to notify the physician and obtain clarification before holding a scheduled dose of methocarbamol, a muscle relaxant, for a resident with multiple medical conditions including muscle weakness, end stage renal disease, and impaired cognitive skills. The nurse held the 6 a.m. dose of methocarbamol after administering Norco, a pain medication, believing that muscle relaxants should not be given concurrently with narcotics due to the risk of respiratory compromise. However, there was no physician order or documentation supporting this decision, and the reason for holding the medication was not recorded in the Medication Administration Record or Nursing Progress Notes. Facility policy required that medications be administered as prescribed and that any concerns about medication appropriateness or potential adverse consequences be discussed with the attending physician or medical director. The Director of Nursing confirmed that nurses were expected to assess residents and administer medications as ordered unless otherwise specified by a physician, and that holding a scheduled medication without provider notification and order clarification did not meet facility expectations. This resulted in an unapproved alteration of the resident's medication regimen.