Failure to Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to administer medications as ordered by physicians for three residents. One resident with a history of seizures, hypertension, diabetes, and dysarthria did not receive a prescribed topical analgesic (Biofreeze) to the right shoulder as ordered. During observation, the assigned nurse did not administer the medication and later stated she thought she had done so. Another resident with polyneuropathy, diabetes, osteoarthritis, knee pain, vitamin D deficiency, and anemia did not receive a prescribed Salonpas pain relieving patch (lidocaine) to the knees or a Vitron-C tablet for anemia. The nurse on duty administered a different medication (lidocaine and prilocaine cream) instead of the prescribed patch and did not administer the Vitron-C tablet, citing unavailability of the medication. A third resident with diabetes, osteomyelitis, and peripheral vascular disease did not receive a prescribed Jardiance oral tablet for diabetes, as the medication was not available at the time of administration. Both the pharmacist and the Director of Nursing confirmed that these residents should have received their medications as ordered. The deficiencies were identified through record review, medication administration observations, and staff interviews.