Failure to Follow Medication Orders and Document Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure that provider orders for medication administration were consistently followed and that non-pharmacological interventions (NPI) were initiated prior to administering as needed (PRN) pain medications. For one resident with multiple diagnoses including heart, lung, and kidney disease, and hypertension, the provider's order specified that midodrine should be held if the systolic blood pressure was greater than 120. However, review of the medication administration records over several months showed that licensed nurses administered midodrine multiple times when the resident's systolic blood pressure exceeded the specified parameter. Both a Licensed Practical Nurse and the Director of Nursing Services confirmed that the expectation was to hold the medication as ordered, but this was not done. Additionally, three other residents with various diagnoses, including depression, diabetes, bipolar disorder, osteomyelitis, pressure ulcer, heart failure, fractures, and acute kidney failure, were administered PRN pain medications such as acetaminophen and oxycodone without documentation that NPIs were offered or provided beforehand. Medication administration records for these residents showed repeated instances where pain medications were given without any record of NPIs being attempted or documented, as required by facility policy. Interviews with nursing staff and the Director of Nursing Services confirmed that NPIs should have been offered and documented prior to administering PRN pain medications, but this was not consistently done. The facility's own policy required licensed nurses to be familiar with medications, especially those with boxed warnings, and to monitor and document appropriate parameters and interventions. The lack of adherence to these policies and provider orders resulted in residents receiving medications without proper justification or prior use of alternative interventions, as evidenced by the documentation and staff interviews.