Failure to Administer Prescribed Antiviral Medication as Ordered
Penalty
Summary
Facility staff failed to ensure that two residents received their prescribed Paxlovid antiviral medication for the full duration as ordered by their physicians. Both residents had multiple significant diagnoses, including epilepsy, cerebral infarction, and malignant neoplasm of the liver, and were diagnosed with COVID-19 during their stay. Physician orders and care plans clearly directed that each resident was to receive Paxlovid twice daily for five days, totaling ten doses per resident. Medical record reviews and Medication Administration Records (MAR) revealed that the residents did not receive the full course of medication as ordered. One resident received only six out of ten doses over three days, while the other received seven out of ten doses over three and a half days. Documentation showed repeated notes indicating that the pharmacy was called regarding the medication, but there was no evidence that the orders were adjusted or that the full course was administered as prescribed. Staff interviews confirmed that facility leadership, including the DON and Infection Preventionist, were unaware that the residents had not received the complete course of Paxlovid. The deficiency was further substantiated by a complaint received by the State Agency, which reported that patients had not received medication for several days and described medication errors and staffing issues. The failure to administer medications as ordered was not identified or addressed by facility staff prior to the survey.