Failure to Adhere to Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during a recertification survey. Specifically, a Licensed Practical Nurse (LPN) administered two cardiovascular medications, diltiazem and metoprolol, to a resident without obtaining the required vital signs, such as heart rate and blood pressure, as per physician orders. The resident, who had diagnoses including atrial fibrillation, hypertension, and chronic kidney disease, was severely cognitively impaired. The physician's orders specified that the medications should be withheld if the heart rate was less than 60 beats per minute or systolic blood pressure was less than 100, and the LPN failed to check these parameters before administration. Additionally, the LPN crushed the metoprolol extended-release tablet despite a pharmacy label indicating 'do not crush.' This action was acknowledged as an error by the LPN during an interview. The facility's policy on medication administration required nurses to question unclear or potentially erroneous medication orders and to check and document vital signs for medications with specific parameters. The failure to adhere to these protocols resulted in the administration of medication without proper assessment, as confirmed by the absence of documented vital signs in the resident's electronic medical record.
Plan Of Correction
Plan of Correction: Approved March 17, 2025 1. Assessed resident #110 for any adverse reactions; none were noted. 2. The nurse manager was notified of the errors, and the Licensed Practical Nurse was immediately re-trained on proper medication administration. The facility has initiated identifying the resident's ability to take medication as a banner in the EMR. 3. The nurse educator initiated immediate and ongoing education on medication administration, documentation, and error prevention strategies for all Licensed Practical Nurses. Conduct medication pass observation for all Licensed Practical Nurses to ensure proper techniques and adherence to policies and procedures, starting 03/10/2025. 4. Implement two to three random weekly medication pass audits. These results will be presented to the QA committee monthly for three months. The committee will determine the frequency of the audits thereafter. Responsible Party: Director of Nursing