Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of Midodrine Hydrochloride for a resident diagnosed with Parkinson's Disease. The resident, who was cognitively intact and required assistance with personal care, had a physician's order to receive 2.5 mg of Midodrine Hydrochloride twice daily, with the stipulation to hold the medication if the resident's systolic blood pressure (SBP) exceeded 120. However, the medication was administered multiple times over several months when the resident's SBP was above the specified threshold. The Medication Administration Record (MAR) for the resident showed instances in October, November, December, and January where the medication was given despite the SBP readings being higher than 120, with values ranging from 122 to 150. An interview with the Director of Nursing confirmed that the medication was improperly administered on these occasions, contrary to the physician's orders. This oversight indicates a failure in following professional standards of practice and the resident's care plan, as required by the quality of care regulations.
Plan Of Correction
1. Resident 9 suffered no ill effects. The Medical Director was notified of resident 9 receiving medication outside of parameters. No new orders given. 2. A baseline audit was completed on all residents currently receiving the medication Midodrine to check for error in documentation. 3. All licensed nursing staff were educated on the process of documenting medications not given due resident being outside of parameters. 4. Audits on residents receiving medications with parameters will be completed weekly x4 weeks and monthly x 2 months to ensure compliance. Results will be reported and trended through the facility's Quality Assurance Committee. 5. Date of compliance 4/5/2024