Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to adhere to physician orders regarding the administration of medications for two residents, identified as R3 and R33. Resident R3, who has a diagnosis of dialysis-induced hypotension and congestive heart failure, was prescribed Midodrine HCL to manage low blood pressure, with specific instructions to hold the medication if blood pressure exceeded 120/70. However, a review of the medication administration record for December 2025 revealed that the medication was administered outside of these parameters 24 times. Similarly, Resident R33, diagnosed with hypotension and acute respiratory failure with hypoxia, was also prescribed Midodrine HCL with instructions to hold the medication if systolic blood pressure was greater than 120 or diastolic blood pressure was greater than 80. The medication administration record for March 2025 showed that the medication was administered outside of these parameters 13 times. An interview with the Director of Nursing confirmed these medication errors, indicating a failure by the facility to ensure that the medication orders for Residents R3 and R33 were followed correctly.
Plan Of Correction
1. Resident R3 no longer resides in the facility. R33 continues on Midodrine. Physician orders/parameters followed as ordered. 2. Current residents on Midodrine have been reviewed by DON or designee to ensure Midodrine physician orders followed as ordered. 3. Licensed staff will be educated by the DON or designee on Midodrine parameters. 4. Random audits of residents on Midodrine will be completed by DON or Designee weekly x4 to ensure medication is administered per physician orders.