Failure to Administer Medication per Physician's Orders
Penalty
Summary
The facility failed to ensure that medications were administered to a resident according to physician's orders. A resident with multiple diagnoses, including interstitial pulmonary disease, COPD, chronic respiratory failure, congestive heart failure, and pulmonary hypertension, was admitted to the facility and had a physician's order for Incruse Ellipta inhalation to be given once daily for COPD. Review of the medication administration record showed that the resident did not receive the prescribed inhaler from 11/28 to 12/1, resulting in four missed doses. Interviews with the resident's significant other and nursing staff confirmed that the medication was not administered as ordered, with the inhaler remaining unopened for several days after admission. Staff interviews revealed confusion regarding the availability and administration of the medication. The resident's significant other reported being told by nursing staff that the inhaler was not available due to a need for prior authorization, and that the medication was not on the nurse's schedule to administer. Nursing staff acknowledged that only two doses had been used during the resident's six-day stay, and the DON stated that medications should be available upon admission and that nurses are expected to communicate when medications are not available. The facility's policy requires all medications to be administered as ordered by a healthcare professional.