Failure to Follow Medication Orders and Documentation Standards
Penalty
Summary
The deficiency involves failures in medication administration and documentation that did not meet professional standards or comply with facility policy. For one resident with hypertension, hyperlipidemia, and moderate cognitive impairment, the facility’s records included staff statements indicating that a nurse administered omeprazole, an antacid medication, to this resident even though it was intended for another resident. Another nurse documented that the resident reported being given an antacid pill and refusing a thyroid pill because they were not on that medication. These events show that the resident received a medication without a valid physician’s order and that the nurse did not correctly identify the resident before administering the drug, contrary to the facility’s policy requiring use of two identifiers and adherence to the six rights of medication administration, including right resident and right drug. A second deficiency involved another resident who was admitted with multiple serious diagnoses, including traumatic subdural hemorrhage, history of falling, protein-calorie malnutrition, lung cancer, and secondary malignant neoplasm of the cerebral meninges, and who was non-verbal. The physician’s order dated 2/14/26 directed that ondansetron 8 mg be given via G-tube every 8 hours as needed (PRN) for nausea or vomiting. This order was transcribed to the resident’s MAR as a PRN medication, and the MAR showed a PRN entry on 2/18/26. Progress notes documented that the resident vomited after a bolus feeding on one shift and had another vomiting episode at 6:20 AM on a later date. Further review of the medical record showed that there was no documentation that PRN ondansetron was administered at the times when vomiting or nausea were documented, nor was there documentation explaining why the medication was not given when the resident had nausea or vomiting. Additionally, progress notes recorded that ondansetron was administered on two separate occasions with positive effect, but there was no corresponding documentation on the MAR to show that the PRN medication had been signed out as given. These omissions conflicted with the facility’s medication administration policy, which requires that medications be administered as ordered by the physician and that the MAR be reviewed to identify the medication and signed after administration.
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