Significant Medication Errors Due to Late Administration and Failure to Hold Antihypertensives
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors in multiple instances. In one case, a nurse administered gabapentin and other medications to a resident later than the physician-ordered time frame. The nurse split the medication pass, resulting in five medications, including gabapentin, being given after the acceptable window. The nurse acknowledged the error, stating that the medications were supposed to be administered by a certain time and that late administration could cause medical complications. In two other cases, the facility did not follow physician-ordered parameters for holding blood pressure medications. For one resident, amlodipine was administered on two occasions when the resident's systolic blood pressure was below the ordered threshold of 110 mmHg. The nurse confirmed that the medication should have been held according to the order and facility policy. Similarly, another resident received both lisinopril and amlodipine when their systolic blood pressure was below the hold parameter. The nurse involved acknowledged that administering these medications under such conditions could further lower blood pressure. The facility's policies required medications to be administered as ordered by the physician, including holding medications when vital signs were outside prescribed parameters. Staff interviews confirmed awareness of these requirements, but the documented medication administration records showed that these protocols were not followed, resulting in significant medication errors for the affected residents.