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Tag No.: A0405
Based on medical record review and interview, the facility failed to ensure drugs and biologicals were administered in accordance with the orders of the practitioner for one (Patient #3) of 10 medical records reviewed. This had the potential to affect all of the facility's 34 active patients.
Findings include:
The medical record for Patient #3 contained an order entered on the Medication Administration Record on 05/23/20 at 8:56 PM for Furosemide 20 mg intravenous push over one minute for shortness of breath. The medical record did not contain evidence of the Furosemide being administered on 05/23/20.
The findings were shared with Staff Z on 08/10/20 at 4:31 PM and confirmed.