Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and manufacturer instructions for two residents. In one instance, a nurse administered Albuterol inhaler to a resident without shaking the inhaler beforehand, despite the medication label and manufacturer's instructions clearly stating that the inhaler should be shaken prior to use. The nurse later confirmed she was unaware of this requirement. In another case, a nurse administered Clonidine to a resident without first checking the resident's blood pressure, even though the physician's order and medication card specified to hold the medication if the systolic blood pressure was less than 120. The nurse also administered rapid-acting Insulin Lispro to the same resident before the meal tray had been delivered, contrary to manufacturer instructions that the insulin should be given within 15 minutes prior to or immediately after a meal. The nurse acknowledged not following these instructions, and the Director of Nursing confirmed the correct timing for insulin administration.