Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in two separate instances involving medication administration. In the first instance, a resident with type 2 diabetes, unspecified dementia, and dependence on renal dialysis received repeated insulin injections in the same area of the abdomen, specifically the left lower quadrant, over multiple days. The resident's care plan specifically required rotation of insulin injection sites to prevent skin discoloration and tissue damage, and the facility's policy also mandated site rotation. Despite these directives, the Medication Administration Record (MAR) showed that staff administered insulin in the same location repeatedly, and both the LVN and DON confirmed that site rotation did not occur as required. In the second instance, another resident with a history of compression fracture, paroxysmal atrial fibrillation, and chronic obstructive pulmonary disease was prescribed amiodarone with specific hold parameters: the medication was to be withheld if the resident's systolic blood pressure (SBP) was less than 100 mm Hg or if the pulse was less than 60. The MAR indicated that the resident received amiodarone on two occasions when the SBP was below the prescribed threshold. The DON confirmed that the medication should not have been administered under these circumstances and that the medication should have been held and documented as such according to facility policy. Both deficiencies were confirmed through interviews and record reviews with facility staff, including the DON and LVN. The facility's own policies and procedures, as well as the residents' care plans and physician orders, were not followed in these cases, resulting in medication administration practices that did not meet professional standards of quality.