Failure to Follow Protocols for Neurological Checks and Medication Administration
Penalty
Summary
The facility failed to adhere to its protocol for completing neurological checks following a fall for one resident. This resident, who was moderately cognitively impaired and had diagnoses including peripheral vascular disease and atrial fibrillation, was found on the floor without injury. However, later that day, the resident exhibited symptoms such as right-sided weakness, mouth drooping, and confusion. Although a neurological assessment form was initiated, the assessments were not completed according to the facility's protocol, which required checks every 15 minutes for one hour, every hour for four hours, and every four hours for 19 hours. Additionally, the facility did not administer medications as ordered by the physician for another resident. This resident, who was cognitively intact and had diagnoses of heart failure and hypotension, was prescribed Midodrine to be administered with meals on specific days, provided their systolic blood pressure was below 120 mmHg. Despite this, the medication was administered on several occasions when the resident's systolic blood pressure exceeded 120 mmHg. The Assistant Director of Nursing confirmed that the neurological assessments and medication administration were not conducted as per the facility's protocols.
Plan Of Correction
1. Resident 37 did not have documented neurological assessments (neurochecks) fully completed prior to transfer to hospital. Medication error completed on resident 76, hold parameter clarified, resident notified and Medical Director notified. There were no ill effects to resident 76. 2. Licensed Staff educated on completion of neurochecks and following hold parameters for midodrine. 3. Director of Nursing or designee will review neurochecks for completion weekly times four weeks and monthly times two months. Director of Nursing or designee will audit residents with midodrine hold parameters weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.