Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician's orders for a resident with heart failure and high blood pressure, identified as Resident 16. The resident's care plan included specific instructions for administering Carvedilol and Lisinopril based on the resident's apical pulse. On multiple occasions in January, February, and March 2025, the facility did not adhere to these orders. Specifically, on January 6, 2025, Carvedilol was administered without obtaining the required apical pulse, which should have been held if the pulse was below 50 bpm. Additionally, Lisinopril was inappropriately withheld on January 22 and 30, and February 13 and 23, 2025, despite orders to administer it daily. On March 23, 2025, Carvedilol was withheld when the resident's apical pulse was 71 bpm, contrary to the physician's orders. The Director of Nursing confirmed these discrepancies during an interview on April 3, 2025.