Failure to Follow Professional Standards in Medication and Treatment Administration
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication and treatment administration for multiple residents. For one resident with an order for lorazepam twice daily, the controlled drug record showed only one dose dispensed on several days, while the medication administration record documented two doses as given, indicating a discrepancy in controlled medication handling and documentation. Another resident with an order for metoprolol, which included specific blood pressure and pulse parameters, received the medication even when the required assessments were not performed or when the parameters were not met, such as administering the drug when the systolic blood pressure was below 120 or the pulse was below 60, contrary to the physician's order. A third resident with congestive heart failure had a physician's order for daily weights and notification if weight increased by more than 2.5 pounds in 24 hours or 5 pounds in a week. Documentation showed missing daily weights, repeated use of a previous day's weight, and a failure to notify the provider when the resident's weight increased by more than 2.5 pounds in 24 hours. For another resident with a fentanyl patch order, the patch was not changed as scheduled, and the resident was observed with a medication cup containing multiple pills and two capsules left on the overbed table, with no assessment completed to determine if the resident could safely self-administer medications. Additionally, on the Oak and Maple Units, several resident treatments were not documented as completed during specific shifts. The facility's documentation practices did not align with professional standards, as required pre-assessment data and timely documentation of medication and treatment administration were not consistently performed. These findings were confirmed through observation, record review, and interviews with facility leadership.