Failure to Administer Admission Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that medication orders for a newly admitted resident were accurately entered into the electronic medical record (EMR) and administered according to physician orders. Upon admission, the resident had multiple diagnoses including Type 2 diabetes mellitus with chronic foot ulcer, hypertension, atrial fibrillation, and congestive heart failure. Physician orders specified several medications to be administered at bedtime on the day of admission. However, the medications were entered into the EMR with a start date for the following day, resulting in no medications being administered on the evening of admission. Nurse interviews revealed that the nurse responsible for entering the orders did not verify if any medications were due that evening and did not check the medication dispensing system for availability. The direct care nurse was unaware that scheduled medications should have been administered that night due to the EMR start date. The Director of Nursing was not aware of the missed doses, and the physician confirmed that medications should have been given as ordered on the admission date. As a result, the resident did not receive any of the prescribed medications on the evening of admission.