Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for medication administration for three residents, resulting in a deficiency. Resident 121, who was diagnosed with hypertension and end-stage renal disease, had a physician order for Carvedilol with specific instructions to hold the medication if the systolic blood pressure was less than 100 mm Hg or the heart rate was less than 60 beats per minute. However, the Medication Administration Records for December 2024 and January 2025 showed that the medication was administered without documented evidence of blood pressure or heart rate checks prior to administration. Similarly, Resident 124, with diagnoses of hypertension and chronic atrial fibrillation, had a physician order for Atenolol with instructions to hold the medication under the same conditions. The records from November 2024 to January 2025 indicated a lack of consistent documentation of vital signs before administration. Resident 46, diagnosed with hypertension, depression, and dementia, had orders for Metoprolol and Norvasc with specific parameters for holding the medication. The records for December 2024 and January 2025 also lacked evidence of vital sign monitoring before administering these medications. An interview with the Clinical Operations Executive confirmed the failure to consistently obtain and document the necessary vital signs before medication administration for these residents.
Plan Of Correction
1. There is no way for the facility to retroactively address resident #121's supplemental documentation. Drug was discontinued on 01/16/2025. Resident #124's heartrate and blood pressure parameters, per physician order, were added to the physicians order effective 01/23/2025. Nursing staff is collecting this clinical information and administering based on parameters. Resident #46's heartrate and blood pressure parameters, per physician order, were added to the physicians' orders effective 01/23/2025. Nursing staff is collecting this clinical information and administering based on parameters. 2. A review was completed by the Director of Nursing on 02/05/2025 of vasoactive, antiarrhythmics, and antihypertensive orders for in-house residents to assure clinical parameters, as ordered by the physician, are in place and being utilized in the administration of the medications. 3. The Clinical Coordinator or designee will educate licensed nursing staff regarding the requirement to assure clinical parameters for medication, as ordered by the physician, are in place and being utilized in the administration of the medications. 4. The DON or designee will complete a weekly review of vasoactive, antiarrhythmics, and antihypertensives for newly admitted and current in-house residents to assure clinical parameters for medication, as ordered by the physician, are in place and being utilized in the administration of the medications. This review will continue weekly for the next three months. Audit results will be reported to the Quality Assurance Performance Improvement committee monthly for three months to ensure continued compliance.