Failure to Administer and Document Ordered Medications and Physician Notification
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure medications were administered as ordered and in accordance with physician prescriptions and facility policy. For one resident with chronic respiratory failure, diabetes mellitus, chronic kidney disease, and depression, physician orders included Albuterol Sulfate inhalation three times daily for shortness of breath, Clonidine every eight hours for hypertension, Gabapentin three times daily for pain, and Hydralazine three times daily for hypertension. Review of the MAR showed these medications were not administered on multiple specified dates and times, and nursing progress notes contained no explanation for the missed doses and no documentation that the physician was notified. The resident reported that at times medications were not administered as ordered, and the DON confirmed the medications were not given and could not explain why, nor was there documentation of physician notification. For a second resident with chronic kidney disease, depression, anxiety, and diabetes mellitus, physician orders included Gabapentin three times daily for pain, Lipitor at bedtime for hyperlipidemia, Pantoprazole Sodium in the morning for GERD, and cranberry twice daily for UTI prophylaxis. The MAR for January and February showed a code indicating “other” for several scheduled doses of these medications. Nursing progress notes documented that Gabapentin, Lipitor, and Pantoprazole were not administered because they were on order, and cranberry was not administered because it was unavailable on the cart. There was no documentation that the physician was informed that these medications were not administered. The resident reported not receiving medications as expected, and the DON verified the missed doses and lack of physician notification. For a third resident with paranoid schizophrenia, adult failure to thrive, depression, pain, and dementia, physician orders included Aricept in the afternoon for Alzheimer’s disease and Sodium Chloride tablets three times daily for low sodium. The MAR for February and March showed a code indicating “other” for multiple scheduled doses of Sodium Chloride and one dose of Aricept. Nursing progress notes indicated that Sodium Chloride and Aricept were on order and not available to be administered on the documented dates and times. There was no documentation that the physician was updated about these missed doses. The DON confirmed that the resident did not receive the ordered Sodium Chloride and Aricept doses and that the physician was not notified. Facility policy required medications to be administered in a safe and timely manner in accordance with prescriber orders, including required time frames.
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