Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to implement physician's orders for a resident diagnosed with hypertension and atrial fibrillation. The physician's orders required the administration of metoprolol and amiodarone once daily, with the stipulation that these medications should not be given if the resident's systolic blood pressure (SBP) was below 110 mmHg. However, a review of the medication administration records revealed that staff administered these medications twice in February 2025 when the resident's SBP was below the specified threshold. This was confirmed by the Director of Nursing during an interview.
Plan Of Correction
1. Resident 93 did not sustain any adverse effects from receiving the medication. Physician was made aware of resident 93 receiving medication outside of parameters. 2. To identify other residents who have the potential to be affected, the DON/designee completed an audit of residents prescribed medications with parameters. 3. To prevent this from recurring, the DON/designee completed education with licensed nurses on checking and following parameters prior to medication administration. 4. To monitor and maintain ongoing compliance, the DON/designee will audit 10 residents with medication parameters to ensure accuracy of medication administration weekly x 4, biweekly x 2, and monthly x 1. Results will be reviewed at the QAPI meeting.