Failure to Clarify and Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure proper clarification and administration of physician orders for a resident with severe cognitive impairment and a history of neuropathy and falls. Specifically, licensed nurses did not clarify two separate physician orders for famotidine, resulting in the resident receiving double doses of the medication on multiple days. The orders included one for a daily dose and another for administration before breakfast, but both were administered without clarification, as confirmed by staff interviews and medication administration records. Additionally, the facility did not ensure that licensed nurses followed the physician's order for administering guaifenesin and dextromethorphan-guaifenesin. The orders specified that these medications should be given every six hours as needed, but the resident received doses of guaifenesin and dextromethorphan-guaifenesin only three hours apart. Staff interviews confirmed that these medications were considered the same and that the six-hour interval was not maintained. Review of facility policy indicated that medications are to be administered as prescribed and that any concerns about dosage or potential adverse consequences should be clarified with the prescriber. Despite this, the nurses did not clarify the orders or follow the prescribed administration intervals, leading to medication errors for the resident.