Failure to Administer Medication as Prescribed and Ensure Timely Refills
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction and hemiparesis did not receive medication as prescribed and experienced a delay in medication refills. During a medication administration observation, an LPN prepared and administered several medications, including Lactulose, but used a bottle labeled for a different resident. The LPN stated that the resident was out of their prescribed Lactulose and that it had to be reordered. The medication was last reordered over a month prior, and the LPN admitted to only reordering it on the day of the observation. Further review revealed that the LPN administered 30ml of Lactulose, despite the physician's order specifying 15ml twice daily. The LPN initially believed the order was for 30ml, but upon checking the electronic record, confirmed the correct dose was 15ml. This resulted in the resident receiving an incorrect dose and medication from a bottle not labeled for them, as well as a lapse in timely medication refills.