Failure to Administer Medication per Ordered Parameters
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including chronic atrial fibrillation, heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, and pulmonary embolism, was administered Midodrine outside of the prescribed parameters. The physician's order specified that Midodrine 10 mg should be given three times daily for hypotension, but only if the resident's systolic blood pressure was 110 or less. Despite this, the medication was administered on several occasions when the resident's systolic blood pressure was above 110, as documented in the Medication Administration Record. Specifically, the medication was given on multiple dates when the resident's systolic blood pressure readings ranged from 112 to 120, contrary to the order. The Director of Nursing confirmed that the medication was administered outside the specified parameters on several occasions, based on both the MAR and staff interviews. The nurse responsible acknowledged that if the medication was signed off as administered, it was indeed given, despite the blood pressure readings being above the ordered threshold.
Plan Of Correction
The facility will continue to ensure medications are administered per physician order. Resident #76 continues to reside at the facility. On 4/1/2025, the DON reviewed the current medication order for midodrine and parameters with resident’s Dr. Chiu. Dr. Chiu reviewed current blood pressures and ordered midodrine to be given daily and to discontinue blood pressure parameters to hold medication. An initial audit was conducted by the DON reviewing medications to treat hypertension and hypotension to ensure current medications with parameters are being followed. Negative findings were reported to the PCP for review and further recommendations. By 4/17/2025, the DON and/or designee will reeducate licensed nursing staff on ensuring they are following the direction in the electronic MAR when completing a medication administration. Ensuring notifications are conducted timely when blood pressure results are outside the parameters given by the prescriber, following those parameters, and properly documenting in the medical record. Weekly for 2 weeks or as directed by the QA committee, the DON will randomly audit residents on hypertensive or hypotensive medications ensuring parameters are being followed, prescribers are notified as directed, and proper documentation is recorded in the medical record. Negative findings will be reported to the QA committee for review. Negative findings will be corrected by notifying the prescriber and reeducating staff. The Administrator will ensure completion of weekly audits. The DON is responsible for the ongoing compliance.