Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to administer medications as prescribed by physicians for two residents. One resident, with diagnoses including glaucoma, anxiety disorder, and major depressive disorder, did not receive all required doses of her prescribed eye drops (brimonidine tartrate) on two occasions, as confirmed by both her statements and a review of the Medication Administration Record (MAR). The MAR was not signed for these doses, and the nurse responsible could not provide an explanation for the missed documentation or administration. Another resident, with complex medical conditions including cellulitis, MRSA infection, and an open wound, did not receive his prescribed intravenous antibiotic (daptomycin) on three separate occasions. The MAR confirmed these missed doses, and the Assistant Director of Nursing acknowledged that the antibiotic should not have been missed to ensure proper treatment of the infection. The nurse practitioner indicated that insurance issues delayed approval for the medication, leading to a change in antibiotic therapy after several missed doses. Facility policy and job descriptions require medications to be administered as ordered and documented accordingly.