Failure to Adhere to Professional Standards in Medication Administration and Monitoring
Penalty
Summary
The facility failed to meet professional standards of nursing practice by not properly obtaining accurate orthostatic blood pressure readings for two residents. For Resident 25, the orthostatic blood pressure readings were suspiciously identical on multiple occasions, indicating a potential error in measurement. The Director of Staff Development noted that the readings for both lying and sitting positions were the same on several dates, which is unlikely as there should always be a difference. Similarly, for Resident 1, the orthostatic blood pressure readings were also found to be the same for lying and sitting positions on different dates, and a Licensed Vocational Nurse admitted to not knowing how to properly take these measurements. The facility also failed to ensure that medication was administered to the correct site as ordered by the physician for Resident 96. The resident was supposed to receive Diclofenac Sodium External Gel 1% applied to both knees for pain, but it was instead applied to the right shoulder. The Licensed Vocational Nurse acknowledged the error and admitted to not realizing there was no order for the shoulder application, which could potentially lead to adverse reactions or harm to the resident. Additionally, the facility did not administer Midodrine HCI according to the physician's parameters for Resident 55. The medication was given even when the systolic blood pressure was above the specified limit, and the 10:00 p.m. dose was administered despite instructions not to give it after the evening meal or less than 3-4 hours before bed. The Director of Nursing confirmed that the medication should have been held when the blood pressure was above the limit and that the 10:00 p.m. dose should not have been given, as it could cause potential harm to the resident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/10/25, License Vocational Nurse (LVN) 4 received one-on-one in-servicing with return demonstration by the Director of Nursing and Director of Staff Development to ensure she understood the definition of orthostatic hypotension and how to perform orthostatic hypotension monitoring. On 3/17/24, Resident 55 started Midodrine HCI 5 mg, give 5 milligrams (mg) orally every 8 hours for hypotension; hold if systolic (top number in a blood pressure reading) blood pressure (SBP) is greater than 110, not to be taken after the evening meal or less than 3-4 hours before bed. Resident 55 was noted to have received medication Midodrine HCI 5 mg outside of parameters. No adverse or negative outcome was noted for Resident 55 as a result of this deficient practice. On 3/10/25, Licensed Vocational Nurse (LVN) 4 received an on-one-one in-service on administering medication per physician order. There were no negative or adverse outcomes for Resident 96 as a result of this deficient practice. On 3/14/25, LVN 4 received an order from Resident 96's Primary Physician for pain medication (Diclofenac Sodium External Gel 1%) to be administered to the left shoulder. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/19/25, the Medical Record Director conducted an audit on residents receiving orthostatic hypotension monitoring to ensure orthostatic hypotension monitoring was being recorded accurately. There was 1 other resident affected by this deficient practice. The residents affected by this deficient practice experienced no negative outcome. On 3/10/25, the Director of Nursing conducted interviews on residents who have topical pain medication orders to ensure residents are receiving topical pain medication as ordered. No other residents were affected by this deficient practice. On 3/24/25, the Medical Records Director conducted an audit on residents with blood pressure medication orders to ensure medication is being administered within parameters ordered by the physician. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/19/25, the Director of Nursing and Director of Staff Development in-serviced Nursing Staff including, but not limited to LVNs and Registered Nurses on the facility's policy and procedure titled, "Blood Pressure, Measuring" with emphasis on orthostatic hypotension being defined as 20 millimeters of mercury (mmHg) decline in systolic blood pressure (the contraction phase of the heart) or a 10 mmHg decline in diastolic blood pressure (relaxing phase of the heart) upon standing and to measure orthostatic hypotension, note the changes in both the systolic and diastolic blood pressure in the standing position compared to the sitting position. The Medical Records Director will conduct an audit on orthostatic hypotension monitoring daily for five days, weekly for two weeks, and monthly thereafter for 3 months to ensure residents' orthostatic hypotension monitoring is being recorded accurately. On 3/21/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to LVNs and RNs, on the facility's policy and procedure titled, "Medication - Administration," with emphasis on testing and taking of vital signs, upon which administration of medications or treatments are conditioned, performing required tests, and recording results. The in-service also included when administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record. The in-service emphasized reviewing the resident's MAR for allergies and/or special considerations for administration, including vital sign parameters and lab results as appropriate. The Medical Records Director will conduct an audit on the following parameters for administering medication for residents with blood pressure medication orders daily for five days, weekly for two weeks, and monthly thereafter to ensure residents' parameters are being followed. On 3/21/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to LVNs and RNs, on the facility's policy and procedure titled, "Medication - Administration," with emphasis on providing professional standards of practice for safe administration of medications for residents in the facility, including following information about any medication they are administering, the drug's route of administration, the drug's indication for use, and desired outcome. The in-service also emphasized the seven "rights" of medication when administering medication: right medication, right amount, right resident, right time, right route, right indication, and right outcome, and the "rule of 3" (performing 3 checks): comparing the physician's order, pharmacy label, and medication administration record (MAR). On 3/31/25, the Director of Nursing/ designee revised orders for residents with pain medication being administered topically to include documentation requirements for where the licensed nurse administered the medication to ensure medication is being administered to the site as ordered. The Medical Records Director will conduct an audit on the following parameters for administering medication for residents with topical pain medication orders daily for five days, weekly for two weeks, and monthly thereafter to ensure residents' parameters are being followed. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for orthostatic hypotension monitoring being monitored accurately, following parameters for administering medication for residents with blood pressure medication orders, and medication administration related to pain medication being administered to the correct site as ordered for three months or until compliance is met.