Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders and implement the comprehensive care plan for a resident with a history of atrial fibrillation, hypertension, type 2 diabetes, and stroke. The resident was prescribed Hydralazine 100 mg three times a day for hypertension, with specific parameters to hold the medication if the systolic blood pressure was less than 110 or the heart rate was less than 65. Despite these orders, the medication was administered outside of the prescribed parameters multiple times in February and March 2025, as documented in the Medication Administration Record (MAR). The Licensed Practical Nurse (LPN) involved admitted to administering the medication even when the heart rate was below the specified threshold, citing a lack of awareness of the updated order parameters. The Director of Nursing (DON) acknowledged that the nurses were not correctly following the physician's orders for the resident's medication. The facility's policies on Medication Regimen Review and Medication Administration, which emphasize the importance of adhering to physician orders and professional standards, were not followed. The failure to act upon the pharmacist's recommendations and ensure that the nursing staff was aware of and adhered to the current medication parameters contributed to the deficiency.
Plan Of Correction
Resident #43 was assessed by the physician upon notification of the medication concern. The medication was discontinued, and a new order written for a different medication. An audit of current residents with medications with parameters for administration was completed by the DON and/or designee to ensure medications were administered within the parameters. The physician was notified of any discrepancies. The licensed staff were in-serviced by the DON and/or designee on medication administration guidelines to follow the physician orders, including medication parameters. Weekly audits will be completed by the DON and/or designee for a minimum of three months or until significant compliance has been met to ensure licensed nurses are following the physician orders, including medication parameters. The results of the audits will be submitted to the Administrator for review and discussed at the monthly QAPI committee meeting. The committee will direct improvement to the plan when necessary to achieve and maintain compliance.