Medication Administration Errors for a Resident
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring that licensed nurses accurately administered prescribed medication for one of the sampled residents. Specifically, Resident 29, who was admitted with diagnoses including atherosclerotic heart disease, hypertension, and dementia with mild psychotic disturbance, was prescribed Amlodipine Besylate to manage hypertension. The physician's order specified that the medication should be held if the resident's systolic blood pressure was less than 110, diastolic blood pressure was less than 60, or heart rate was less than 60. Upon review of the Medication Administration Record (MAR) for November 2024 through January 2025, it was found that the medication was administered 19 times outside of the prescribed parameters. On several occasions, the medication was given without documenting the resident's blood pressure or heart rate, and on other occasions, it was administered despite the resident's vital signs being below the specified thresholds. The Director of Nursing confirmed that the nursing staff failed to adhere to acceptable standards of nursing practice during medication administration, resulting in multiple medication errors.
Plan Of Correction
1. Resident 29 was assessed and there were no adverse effects noted. MD/RP aware. 2. 14 days look back was completed to ensure medications with orders for parameters were followed. 3. Licensed Nursing staff were re-educated on the Medication Administration policy with a focus on medication parameters. The DON will complete spot checks of medications with parameters in the orders to ensure parameters are followed. 4. The DON or designee will conduct an audit of medications with parameters weekly x 4 weeks then monthly x 2 months to ensure parameters are followed. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.