Failure to Follow Medication Hold Parameters Results in Unnecessary Drug Administration
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications by not adhering to physician-ordered hold parameters for blood sugar and blood pressure when administering certain medications. For one resident with diabetes, physician orders specified that diabetes medications, including Januvia, should be held if the blood sugar (BS) was less than 110 at 6:00 a.m. Despite this, the medication was administered on multiple occasions when the resident's BS was below the specified threshold, as documented in the Medication Administration Records (MAR) for January through April 2025. Both the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the orders were not followed and that the resident received unnecessary doses on at least ten occasions. Another resident with hypertension had physician orders for three blood pressure medications, each with specific parameters to hold the medication if the systolic blood pressure (SBP) or diastolic blood pressure (DBP) fell below certain levels. The MARs showed that these medications were administered even when the resident's blood pressure readings were below the hold parameters. The DSD and DON both acknowledged that the medications were given when they should have been withheld, as indicated by the lack of circled initials and documentation on the MAR. The facility's policy on administering medications required that medications be given according to physician orders and that any withheld medications be properly documented with circled initials and a reason for withholding. The failure to follow these procedures resulted in the administration of unnecessary medications to both residents, as confirmed by staff interviews and record reviews.