Failure to Follow Medication Administration Parameters
Penalty
Summary
The facility failed to adhere to physicians' orders for two residents, resulting in the administration of medication outside the prescribed parameters. Resident 3, diagnosed with hypertension, had a physician's order to receive lisinopril once daily, provided their blood pressure was not below 110/65 mm/Hg. However, the medication administration records (MARS) indicated that the medication was given once in March and twice in April when the resident's blood pressure was below the specified threshold. Similarly, Resident 5, also diagnosed with hypertension, was prescribed metoprolol tartrate twice daily, with the condition that it should not be administered if the systolic blood pressure was below 100 mm/Hg. Despite this, the MARS showed that the medication was administered four times in April when the resident's systolic blood pressure was below the prescribed limit. The facility's administrator confirmed these discrepancies during an interview.
Plan Of Correction
*What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No negative signs or symptoms related to medications provided outside parameters were identified. Physician will be notified of these occurrences. Med errors will be reported in QAPI. Nurses who were non-compliant will be coached or disciplined. *How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? An audit of medications with parameters will be completed to assure no additional residents received medications outside the parameters ordered. *What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? All licensed nursing staff will be in-serviced to pay attention to medication parameters when administering medications and to follow those orders. All parameters are included on the MAR to assure they are easily visible to nurses to comply with at time of medication administration. *How the corrective action will be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established? DON and Unit Managers or their designee will complete audits of residents with medications containing parameters monthly. These will be completed for the next 4 months to assure nursing is consistent with the following parameters. Pharmacy consultant will also be asked to randomly audit the MAR for medication parameter compliance. Any noncompliance identified will be addressed with coaching and or disciplinary action.