Failure to Accurately Transcribe and Administer Premedication Orders for Comfort
Penalty
Summary
The facility failed to accurately transcribe and implement a physician's order for premedication to promote comfort and prevent discomfort during care for one resident. The physician's order specified that the resident should be premedicated with Ativan (Lorazepam) 0.5 mg and Morphine 10 mg every two hours as needed prior to care. However, the facility's transcribed orders did not include the instruction to administer both medications together prior to care, and the Morphine order lacked the premedication instruction entirely. Review of the Medication Administration Record (MAR) and nursing documentation showed that the resident was repositioned multiple times, but there was no evidence that both PRN Lorazepam and PRN Morphine were administered together as ordered before care was provided. The resident, who had diagnoses including diabetes, dementia, and hypertension, was observed to experience increased discomfort, moaning, and anxiety during repositioning and incontinence care, as documented in nursing progress notes. Staff interviews confirmed that the orders were not transcribed as written by the physician, and the Director of Nursing acknowledged the omission. Facility policy required that PRN medication orders specify the reason for administration and symptoms for which the medication is prescribed, but these requirements were not met in this case.