Failure to Administer Parkinson’s Medication at Ordered Times
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when nursing staff did not administer a resident’s Parkinson’s medication at the physician-ordered times. The resident had an order for Carbidopa-Levodopa oral disintegrating tablets, 25-100 mg, 1.5 tablets by mouth every 8 hours for Parkinson’s disease, with instructions to give at the scheduled time and to notify the provider if unable to do so. The Medication Administration Record for the month showed the doses as given but did not document the specific administration times. The facility’s Medication Administration Audit Report, however, showed multiple instances where the medication was administered later than the scheduled times. The audit report documented that one morning dose scheduled for 6:00 a.m. was given at 8:33 a.m., and several afternoon doses scheduled for 2:00 p.m. were given between 3:04 p.m. and 4:00 p.m. These late administrations occurred on multiple days. Prior to these findings, the nurse practitioner had documented that the resident’s family voiced concerns that the Parkinson’s medication was being given later than scheduled and that the resident had increased tremors. In response to these concerns, the NP discussed the issue with nursing and adjusted the order to specify administration every 8 hours at specific times. The resident was an older male with Parkinson’s disease with fluctuations, hypertension, and a traumatic subarachnoid hemorrhage, and had an intact BIMS score of 15. His comprehensive care plan included anti-Parkinsonian therapy with interventions to administer medications as ordered and to monitor and document side effects and effectiveness every shift. Interviews with the administrator and the vice president of clinical operations confirmed that nurses and medication aides were responsible for timely medication administration, that certain medications such as Parkinson’s medications ordered for specific times should follow a one-hour before and after window, and that late administration could affect the conditions being treated. The facility’s Medication Pass Policy stated that medications must be administered at the correct time and frequency as ordered, including the resident’s right to timely and appropriate medication administration.
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