Failure to Administer and Document Physician-Ordered Medications and Treatments
Penalty
Summary
The facility failed to administer prescribed medications and treatments as ordered by the physician for a resident with multiple medical conditions, including epileptic seizures, a pressure ulcer, and chronic kidney disease. Specifically, the resident did not receive scheduled doses of nystatin cream for wound care, Zoryve foam for seborrheic dermatitis, and normal saline flushes for PICC line maintenance on several documented occasions. Review of the Treatment Administration Record (TAR) and IV Administration Record revealed multiple blank entries, indicating missed administrations of these medications and treatments. Interviews with nursing staff confirmed that the absence of documentation on the TAR and IV Administration Record meant the medications and treatments were not given. Both the Licensed Vocational Nurse and the Registered Nurse Supervisor acknowledged that the resident should have received these medications daily as ordered, and that the records should not have contained blank spaces. The staff also confirmed that the missed administrations were not documented as given or offered. The resident reported not receiving his prescribed creams and described feeling unwell as a result. The facility's policy required medications to be administered within one hour of the prescribed time unless otherwise specified, and for all administrations to be documented. The failure to follow physician orders and document medication and treatment administration resulted in the resident not receiving necessary care for his wounds and PICC line maintenance.